MSDs in The Workplace

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MUSCULOSKELETAL DISORDERS IN THE WORKPLACE: ISBN-13: 978-0-323-02622-2
PRINCIPLES AND PRACTICE ISBN-10: 0-323-02622-2
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The Publisher
Library of Congress Cataloging-in-Publication Data
Musculoskeletal disorders in the workplace: Principles and practice / [edited by] Margareta
Nordin, Gunnar B.J. Andersson, Malcolm H. Pope. 2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-323-02622-2
1. Musculoskeletal systemDiseases. 2. Occupational diseases. I.
Nordin, Margareta. II. Pope, M. H. (Malcolm Henry), 1941- III. Andersson, Gunnar, 1942-
[DNLM: 1. Musculoskeletal Diseasestherapy. 2. Biomechanics. 3. Human Engineering.
4. Musculoskeletal Diseasesprevention & control.
5. Occupational Diseasesetiology, WE 140 M9854 2006]
RC925.5M8783 2006
616.7dc22 2006043830
Acquisitions Editor: Rolla Couchman
Project Manager: Bryan Hayward
Printed in United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Foreword
Workers health priorities are now driven by demographics.
All of the First World Nations are facing a future with a rapidly
diminishing work force, an aging population, and a growing
number of pensioners. The prevention and efficient man-
agement of work place injuries and disabilities has become
a priority.
Medical professionals work in an increasingly specialized
world brought on by an explosion of knowledge, the demand
from society for "the very best" in services, and the need for
expertise to keep pace with technological change and innova-
tion. Modern medical history, in particular, is replete with
examples of sudden bursts of information that challenged the
growth of new domains and abilities. The period of World
War II saw an explosion of medical knowledge, rapidly divid-
ing General Surgery into numerous subspecialties. Similarly,
the 1970s was a critical period in orthopaedic surgical practice
as many subspecialties developed that allowed greater expert
use of modern technology.
Occupational orthopaedics is a relatively young specialty
that is still evolving rapidly. As in sports medicine, we have
learned that it is not sufficient to examine and treat injuries
alone. After recovery, an injured football player is expected to
return to the game and perform at his previous level of athletic
ability. The injured industrial worker is also expected to return
to his or her previous level of performance, accomplishing
a particular task within a reasonable time frame. Although
the average orthopaedic surgeon may be well-versed with the
conditions of the gridiron, he or she may not be familiar with
the requirements and limitations of the industrial playing
field. In industrial medicine, it is not only necessary to "fix"
the worker; one must have an idea about how to fix the work-
place to prevent further injury. Like sports medicine, the
management and prevention of industrial injury demands
a dedicated and knowledgeable cadre of physicians, surgeons,
and therapists who are able to apply modern knowledge and
expertise to a successful medical program.
This volume brings together chapters authored by the
most knowledgeable group of surgeons, physicians, scientists,
ergonomists, and therapists currently addressing the preven-
tion and management of workplace injury. The editors have
assembled a most versatile and practical tool for the many
allied-health professionals involved with work-related injuries.
This updated text will have a strong impact within industry
and on the management of patients well into the 21st century.
Victor H. Frankel KNO, MD, PhD
Professor of Orthopaedic Surgery, NYU
President Emeritus, Hospital for Joint Diseases
v
vii
Contributors
K. N. An, Ph.D.
John and Posy Krehbiel Professor of
Orthopaedics
Maylo Clinic College of Medicine
Orthopaedics Biomechanics Lab
Rochester, MN 55905
Gunnar B. J. Andersson, M.D., Ph.D.
Professor and Chairman
Department of Orthopaedic Surgery
Rush-Presbyterian-
St. Lukes Medical Center
Chicago, IL 60612
Thomas J. Armstrong, Ph.D.
Professor
Industrial and Operations Engineering
Director
Center for Ergonomics
University of Michigan
Ann Arbor, MI 48109-2117
Federico Balagu
Mdecin Chef Adjoint
Division of Rheumatology, Physical Medicine
and Rehabilitation
Hpital Cantonal
1708 Fribourg
Switzerland
and
Adjunct Associate Professor
New York University School of Medicine
New York, NY 10014
Michele Crites Batti, Ph.D.
Professor
Department of Physical Therapy
University of Alberta
Edmonton, Alberta T6G 2G4
Canada
Jane Bear-Lehman, Ph.D., OTR, FAOTA
Associate Professor
New York University
Steinhardt School of Education
Occupational Therapy Department
New York, NY 10012
David P. Beason, M.S.
Research Engineer
Laboratory Manager
McKay Orthopaedic Research Laboratory
University of Pennsylvania
Philadelphia, PA 19104
Amit Bhattacharya, Ph.D., C.P.E.
Professor
Biomechanics-Ergonomics Research Laboratories
Department of Environmental Health
University of Cincinnati Medical College
Cincinnati, OH 45267-0056
Anthony M. Buoncristiani, M.D., L.T.
Orthopaedics Department
Naval Medical Center
San Diego, CA 92134
Linda Carroll, M.D.
Associate Professor
Department of Public Health Sciences
Edmonton, Alberta T6G 2E1
Canada
J. David Cassidy, M.D.
Edmonton, Alberta T6G 2E1
Canada
Christine Cedraschi
Division of General Medical Rehabilitation &
Multidisciplinary Pain Center
Division of Clinical Pharmacology and
Toxicology
Geneva University Hospitals
1211 Geneva 14
Switzerland
Mark S. Cohen, M.D.
Rush-Presbyterian-
St. Lukes Medical Center
Chicago, IL 60612
Pierre Ct, D.C., Ph.D.
Scientist
Institute for Work and Health
Toronto, Ontario M5G 2E9
Canada
Benjamin Crane, M.D.
Resident
Rush University Medical Center
Chicago, IL 60612
James N. DeBritz, M.D.
Assistant Instructor
Department of Orthopaedics
Georgetown University Hospital
Washington, DC 20007
Craig J. Della Valle, M.D.
Assistant Professor of Orthopaedic Surgery
Rush-Presbyterian-St. Luke's Medical Center
Chicago, IL 60612
James A. Dewees, M.S., C.P.E., C.E.E.S.
ERGO Accommodations Inc
P O Box 499
Union, KY 41091-0499
Jiri Dvorak, M.D., Ph.D.
Department of Neurology
Schulthess Hospital
8008 Zurich
Switzerland
Ulf Eklund M.D.
Orthopedic Surgeon
Department of Orthopedics
Molndal Hospital
Molndal, Sweden
Freddie H. Fu, M.D.
University of Pittsburgh
Pittsburgh, PA 15203
Douglass Gross, Ph.D.
Assistant Professor
Canada
Robert Gunzburg, M.D., Ph.D.
Senior Consultant
Centenary Clinic
2018 Antwerp
Belgium
Daniel J. Habes, M.S.E., C.P.E.
Industrial Engineer
Industrial Hygiene Section
Hazard Evaluations and Technical Assistance
Branch
Division of Surveillance, Hazard Evaluations,
and Field Studies
National Institute for Occupational Safety and
Health
Cincinnati, OH
Robert H. Haralson, III, M.D., M.B.A.
Executive Director of Medical Affairs
American Association of Orthopaedic
Surgeons
Rosemont, IL 60018
Contributors viii
Rudi Hiebert, B.S.
Interim Director
Musculoskeletal Epidemiology Unit
Occupational & Industrial Orthopaedic Center
NYU Hospital for Joint Diseases
New York, NY 10014
Beat Hintermann, M.D.
Chief Orthopaedic Clinic
University of Basel
Kantonsspital
CH-4410 Liestal
Switzerland
David M. Kalainov, M.D.
Clinical Assistant Professor
Northwestern University
Chicago, IL 60611
Dennis D.J. Kim, M.D.
Associate Professor
Department of Physical Medicine and Rehabilitation
Montefiore Medical Center
Bronx, NY 10467
Stephan Konz, Ph.D., P.E.
Professor
Department of Industrial Engineering
Kansas State University
Manhattan, KS 66506
Vicki Kristman, B.Sc., M.Sc.
Ph.D. Candidate, Epidemiology
University of Toronto
Research Associate
Institute for Work & Health
Toronto, Ontario M5F 2E9
Canada
Shrawan Kumar, Ph.D., D.Sc., F.Erg.S., F.R.S.C.
Professor
Faculty of Rehabilitation Medicine
Canada
Marianne Magnusson, R.P.T., Dr.Med.Sci.
Senior Lecturer
Liberty Safe Work Research Centre
Department of Economy and Technology
Halmstad University
SE-301 18 Halmstad
Sweden
Paul H. Marks, M.D.
Associate Professor
Department of Surgery
Toronto, ON M4Y 1H1
Canada
Ronald Moskovich, M.D.
Assistant Professor
New York, NY 10003
Margareta Nordin, Dr.Sci.
Professor
Departments of Orthopaedics and
Environmental Medicine
School of Medicine
New York University Program Director
Program of Ergonomics and
Biomechanics
Graduate School of Arts and Science
New York University
Director
Occupational and Industrial
Orthopaedic Center (OIOC)
New York University Medical Center
New York, NY 10014
Mooyeon Oh-Park, M.D.
Clinical Associate Professor
Department of Rehabilitation Medicine
Montefiore Medical Center
Bronx, NY 10467
Rita M. Patterson, Ph.D.
Associate Professor and Deputy Director
Orthopaedics Biomechanics Laboratory
Division of Research
Department of Orthopaedic Surgery and
Rehabilitation
University of Texas Medical Branch
Galveston, TX 77555
David I. Pedowitz, M.S., M.D.
Chief Resident
Anthony Petrizzo, M.D
c/o Ronald Moskovich, M.D.
301 East 17th Street
New York, New York 10003
Derek Plausinis, M.D.
Shoulder & Elbow Surgery Fellow
New York, NY 10003
Malcolm H. Pope, Dr.Med.Sci., Ph.D.
Professor
Liberty Safework Research Centre
Department of Environmental & Occupational
Health
Foresterhill
Aberdeen, Scotland AB 25 2ZD
United Kingdom
Laura Punnett, Sc.D.
Professor
Department of Work Environment
University of Massachusetts Lowell
Lowell, MA 01854
Robert G. Radwin, Ph.D.
Professor and Chair
Department of Biomedical Engineering
University of Wisconsin
Madison, WI 53706
David Rempel, M.D., M.P.H.
Professor
School of Medicine Ergonomics Program
Division of Occupational and Environmental
Medicine
University of California, San Francisco
Richmond, CA 94804
Michiel Reneman, Ph.D, P.T.
Center for Rehabilitation
University Medical Center Groningen
University of Groningen
P.O. Box 30002, 9750 RA Haren
The Netherlands
Per A.F.H. Renstrm, M.D., Ph.D.
Professor
Department of Molecular Medicine and
Surgery
Section of Orthopaedics and Sports
Medicine
Karolinska Hospital
SE-171 76 Stockholm
Sweden
Mana Rezai, H.B.Sc., D.C., M.H.Sc. Candidate
Research Associate
Institute for Work & Health
Toronto, Ontario M5G 2E9
Canada
Tonu Saartok, M.D., Ph.D.
Department of Surgical Sciences
Section of Sports Medicine
Karolinska Institute
SE-171 76
Stockholm, Sweden
G. James Sammarco, M.D.
The Center for Orthopaedic Care, Inc.
Cincinnati, OH 45219-2906
Peter Sheehan, M.D.
Director
Diabetes Center of Greater New York
Cabrini Medical Center
New York, NY 10003
Ali Sheikhzadeh, Ph.D., C.I.E.
Research Assistant Professor
Departments of Orthopaedic Surgery and
Environmental Medicine
New York University School of Medicine
Associate Director of Research
Occupational and Industrial Orthopaedic
Center
New York, NY 10014
Mary-Louise Skovron, Dr. PH.
Group Director, Pharmaco-epidemiology
Global Epidemiology
BristolMyers Squibb
311 Pennington-Rocky Hill Road
Pennington, NJ 09534
Louis J. Soslowsky, Ph.D.
Professor of Orthopaedic Surgery and
Bioengineering
Vice Chair for Research
Director, McKay Orthopaedic Research
Laboratory
Dan M. Spengler, M.D.
Professor and Chair
Department of Orthopaedics and
Rehabilitation
Vanderbilt Orthopaedics Institute
Nashville, TN 37232
Marek Szpalski, M.D.
Associate Professor and Chair
IRIS South Teaching Hospitals
Free University of Brussels
1190 Brussels
Belgium
James B. Talmage M.D.
Occupational Health Center
Cookeville, TN 38501
Ross Taylor, M.D.
Coastal Orthopaedic Associates
Conway, SC 29526
Victor Valderrabano, M.D., Ph.D.
Human Performance Laboratory and
Orthopaedic Department
University of Calgary
Calgary, Alberta T2N1N4
Canada
also
Orthopaedic Department
University Hospital of Basel
4031 Basel
Switzerland
Tapio Videman, M.D., D.Med.Sci.
Professor
Faculty of Rehabilitation Medicine
Canada
Sherri Weiser, Ph.D.
Research Assistant Professor of Environmental
Medicine
Occupational & Industrial Orthopaedic Center
New York, NY 10014
Sam W. Wiesel, M.D.
Professor and Chair
Georgetown University Medical Center
Washington, D.C. 20007
Harrit Wittink, Ph.D., M.S., P.T.
Head
Physical Therapy Professional Master Program
Hogeschool Utrecht
3508 AD Utrecht
The Netherlands
Joseph D. Zuckerman, M.D.
Professor and Chair
New York, NY 10003
Contributors ix
C HA P T E R
Introduction to Epidemiologic
Concepts in Musculoskeletal
Disorders
Mary Louise Skovron and Rudi Hiebert
The literature on the epidemiology of occupational musculoskele-
tal disorders is often confusing because of conflicting evidence on
the importance of various potential risk or causal factors. This
chapter describes basic epidemiologic methods so the reader can
evaluate critically the published literature on occupational mus-
culoskeletal disorders. Most examples are drawn from the litera-
ture on occupational low back pain, but the reader should be
aware that similar methodologic standards must be applied to
the literature on upper extremity disorders.
Epidemiology is the study of the distribution and determi-
nants of diseases and injuries in human populations. It consists
of a developed methodology for testing scientific hypotheses in
groups of individuals rather than in a laboratory setting. With
knowledge of the intrinsic strengths and limitations of the design
and execution of studies reported in the literature, it is possible to
evaluate the strength of the evidence derived from these studies
and even to make sense of conflicting results from different studies
on the same topic. In this chapter we present an overview of the
basic terminology used in epidemiology and the characteristics and
generic strengths and limitations of analytic (hypothesis testing)
study designs, with an emphasis on observational study designs.
There are several types of epidemiologic studies. Descriptive
epidemiology is a means of monitoring the health of a population,
identifying health problems, and compiling information that can
be used for the development of causal hypotheses. Analytic epi-
demiology is a set of epidemiologic study methods used to test
specific hypotheses.
MEASURES OF DISORDER FREQUENCY
The fundamental strategy of epidemiology is the analysis of rel-
ative and absolute measures of frequency and a comparison of
the characteristics of individuals with and without disorder. The
most obvious measures of frequency are case counts and their
variations, which are often referred to as numerator data. They
describe the frequency of the disorder without reference to the
underlying population at risk. Examples of sources of case count
data include back injury reports to the Occupational Safety and
Health Administration (OSHA) by employers, workers compen-
sation records, records of visits to the workplace health facility,
and surveys of the work force.
11
In clinical practice, the simple
case count is usually derived by chart review (retrospectively) or
by enrollment of patients seen during a given period (prospec-
tively). The frequency of the disorder can also be expressed as a
proportionate ratio, a ratio of cases of a particular disorder to
cases of all disorders in the population of interest. In 1985 for
example, occupational back injuries accounted for 26% of all
closed compensation cases in a sample of nine states.
By itself, numerator data cannot provide useful information
regarding the risk or probability of acquiring the disorder. The
case frequency has to be related to the underlying population
that could have potentially developed the disorder. For example,
the U.S. Bureau of Labor Statistics estimated 303,750 OSHA-
reportable occupational injuries involving the back in 2003.
4
Without reference to the number of people at risk, it is not pos-
sible to estimate the risk of back injury in the population or to test
hypotheses regarding risk factors for occupational back injury. For
this reason, rates are used when the objective is to assess the risk
of the disorder or determinants of disorders or their outcomes.
Rates and ratios
Rates describe the frequency of a disorder or disorder per unit
size of the population per unit time of observation. The rates
commonly used in epidemiology are morbidity and mortality
rates. The general form of a morbidity or mortality rate is
The most frequently used morbidity rates in epidemiologic
research are the incidence rate and the prevalence rate. The inci-
dence rate is based on new cases of a disorder or disorders (or new
disorder events), whereas the prevalence rate is based on existing
cases. Because they are based on new versus existing cases,
Number of cases
Number of persons at risk
10 00 (1000, etc.) per unit time
1
incidence and prevalence rates have different uses and different
limitations.
In a sense, the incidence rate is a rate of change, the frequency
with which people change from healthy to injured, sick, or dis-
abled. Therefore the appropriate denominator is the population
at risk of acquiring the disorder (i.e., those who are free of the
disorder at the start of the time interval). The incidence rate may
be quantified in a number of ways, for example, as the number
of new events per 1000 persons per year, when the population is
stable and the number of new events is counted each year.
Alternatively, it may be quantified as the number of new events
per 1000 person-years, as is done in prospective studies where a
fixed population is followed until the disorder, the end of the
study, or loss to follow-up occurs. In practice, although the best
denominator for incidence rates is the number of people free of
the disorder at the start of the time interval, surveillance incidence
rates (and prevalence rates) that are based on case reports often use
the total population derived from census data or from work-force
estimates. The U.S. Bureau of Labor Statistics estimate of 303,750
OSHA-reportable occupational injuries involving the back repre-
sents an incidence of 3.46 new cases per 1000 workers.
4
The prevalence rate is the number of existing cases of a disor-
der in a given population in a given time period. For example,
the 1-year prevalence of disabling back pain is as high as 25%.
14
Point prevalence is the number of cases per unit population
at one moment of counting, for example, all persons receiving
disability because of back pain in the work force of a metropoli-
tan electrical utility company on January 1, 2005, expressed per
1000 population. For point prevalence, the unit of time is often
not expressed because the period of time is effectively instanta-
neous. Period prevalence is the number of cases existing at one
time or another during a definable time interval such as 1-year,
5-year, or lifetime prevalence. Some epidemiologists do not
express prevalence as a rate because in practice it is often derived
from surveys that are difficult to assign to a specific time interval.
A number of factors other than the risk factor under study
may affect the incidence and prevalence rates. These include
demographic characteristics of the underlying population, most
obviously age distribution
6
because age is known to be associated
with the onset of almost all disorders. Gender and ethnicity dis-
tributions must also be taken into account when incidence rates
are interpreted. Other influences can distort the apparent inci-
dence rate, including certain company policies, workers com-
pensation claims, and health care system influences that affect
the likelihood of seeking medical attention, of being diagnosed
with a given disorder or disorders, or of having the disorder
reported. These factors should be considered when measures of
disorder frequency are evaluated, particularly when changes are
assessed over time or different populations are compared.
To eliminate the effects of differences in these factors, the rates
may be adjusted or standardized algebraically. The adjusted rates
express the risk of acquiring the disorder in the populations being
compared as if they had the same age, sex, and ethnicity distribu-
tions. Alternatively, if it is not necessary to have a single summary
index of disorder risk, the morbidity rates within population
strata defined by age, sex, and ethnicity may be compared.
The number of existing cases of a disorder or disorders at any
time is a function of both the rate of new cases (incidence) and
the duration of that disorder. Therefore, when a population is
stable and the duration of a disorder is also stable, it is possible
to estimate prevalence from incidence and vice versa according
to the following approximation:
Prevalence ~
~ incidence duration
Thus a change in prevalence may reflect changes in the inci-
dence rate, duration, or both. For example, the prevalence of low
back pain in a population may change because of alterations in
individual, work-related, or other environmental risk factors
affecting incidence rate or because treatment changes alter the
duration of back pain episodes and risk of chronicity. It is occa-
sionally the case that improved treatment extends the duration
of a disorder, with the result that the prevalence increases in the
face of a decreasing incidence, as occurred some decades ago
with Down syndrome. The survival of infants with Down syn-
drome improved because of improved medical and surgical man-
agement of their associated disorders. The prevalence of Down
syndrome increased, although the incidence declined as a result
of prenatal screening programs.
DESCRIPTIVE EPIDEMIOLOGY
The first step often undertaken in epidemiology is development
of the descriptive epidemiology of a disorder or disorders.
Descriptive epidemiology supports the development of causal
hypotheses but does not in itself support conclusions about disor-
der causality or about any hypotheses. In descriptive epidemiol-
ogy the frequency of a disorder in the population is characterized
in terms of person (e.g., age, sex, ethnicity-specific incidence rates,
economic, behavioral, occupational, and other factors), place
(rural versus urban, type of housing, national variations, type of
industry, job requirements), and time (long-term trend, seasonal-
ity, occasionally day of the week or time of day).
The need to explain variation in descriptive studies drives the
formulation of causal hypotheses. Drawing on current available
information from various fields (such as anatomy, physiology,
psychology, behavioral science, etc.), specific hypotheses are
developed by inductive reasoning to explain observed patterns of
variation and then evaluated using specific study designs to test
these hypotheses. Studies that test specific hypotheses are called
analytic. As the results of hypothesis-testing (analytic) studies are
accrued, they are added to the basis for causal inference, depend-
ing on their strengths and generalizability, and hypotheses are
supported, modified, or negated.
In interpreting the evidence from all scientific sources, the
rules of causal inference are applied.
7
Briefly, the hypothesized
cause must be demonstrated to have preceded the disorder by a
length of time sufficient to allow disorder development and
expression (time sequence of events). The disorder should be
more common in those with the hypothesized cause than in
those without it (increased risk in those exposed to the hypothe-
sized cause), and as the intensity or duration of exposure to the
hypothesized cause increases, the frequency of the disorder
should increase (dose-response relationship). The association
between the hypothesized causal factor and the disorder should
be consistently demonstrated in methodologically sound studies
and should be biologically plausible. In addition, the specificity
of an association (i.e., the extent to which the hypothesized
Chapter 1 Introduction to epidemiologic concepts in musculoskeletal disorders 4
causal factor is associated with only one disease or disorder) adds
weight to a causal hypothesis, but it is not necessary for causal
inference; for example, cigarette smoking is accepted as a cause
of lung cancer, although the association is not specific. Cigarette
smoking is also associated with a number of other cancers,
obstructive pulmonary disorder, heart disorder, and a variety of
disorders, including osteoporosis, low back pain, and, in particu-
lar, herniated intervertebral disks.
ANALYTIC EPIDEMIOLOGY
Analytic, or hypothesis-testing, epidemiology relies on two types
of study designs: observational and experimental. In observa-
tional studies, exposure to the hypothesized causal factor and
development of the disorder in the population under study
occur in the natural course of events; the investigator does not
cause them to occur. The study is designed and executed to max-
imize the extent to which it can be seen as a natural experiment,
that is, the extent to which all extraneous sources of variation are
eliminated and only the exposure to the putative cause and the
frequency of disorder vary between populations being com-
pared. It is often the case that once substantial observational
evidence has accrued, causality is widely accepted. However, it is
desirable in etiologic epidemiology and almost universally
required in evaluations of treatment that the final test of the
hypothesis is in interventional or experimental studies.
In experimental studies, the investigator causes individuals or
groups of individuals in the population to receive the treatment
in question. To demonstrate ethically the causal role of a risk fac-
tor for which there is only observational evidence, the investiga-
tor would prevent exposure to the risk factor for a group of
people. In both types of interventional design strategies, a com-
parison group that does not receive the intervention is necessary.
All other factors that might influence the outcome of the study
(potential confounding factors) can be eliminated or controlled
by the investigator. Because the conditions of the study are much
more under control of the investigator, interventional studies can
more closely approximate true experiments than can observa-
tional studies. When such studies are well designed and executed,
they provide very strong support (or negation) for a hypothesis.
All analytic study designs have potential problems of internal
and external validity that must be solved by the investigator
either in the study design or in the data analysis. Internal validity
is the extent to which a study is a true test of the specific hypoth-
esis, that is, the extent to which all possible biases of measure-
ment or information and all possible confounding variables are
eliminated as explaining the observed study result. External
validity is the extent to which the study results can be general-
ized to the population of interest, namely, whether the study
subjects are representative of the population at risk. If the poten-
tial validity problems have been solved in either the design or
analysis of the study, the study evidence is strengthened.
Because it is not possible to study the entire universe of
potentially eligible subjects, epidemiologic studies are conducted
on samples of the population of interest. Even a study of an entire
city or the work force of a company constitutes a sample. The
method of sampling should not introduce selection biases. For
example, a volunteer study is potentially susceptible to selection
bias because the health behavior and health status of people who
volunteer for research are well documented to be better than
those of refusers. No characteristics of the individuals should
affect the likelihood of selection for the study, including their
knowledge of the question at issue; their beliefs about the risk
factors or about the cause of the disorder being studied; or any
characteristic such as age, sex, or education that could be inde-
pendently associated with both the disorder and the hypothe-
sized causal factor.
It is important for the internal validity of the study results
that the information collected is accurate and complete. If there
is inaccuracy (measurement error) in the information collected,
the ability to detect the association of interest is reduced. If the
accuracy of the information is worse for one exposure group
than for another, the effect on the study results may not be
predictable. For this reason, an evaluation of the accuracy (or
validity) of measurements is necessary for any study. Research
reports should describe the validity of the sources of information.
Questionnaires or reporting methods that have been validated in
the study population or in similar populations or circumstances
should be used. The problem of validity of information is partic-
ularly important in research on occupational musculoskeletal
disorders because the methods of both case diagnosis
13
and
measurement of work exposure
17
have substantial limitations.
Before specific study designs can be discussed, the term con-
founding must be defined. Confounding occurs when the study
results can be explained by a factor extraneous to the hypothesis
being tested. A potential confounding factor must be associated
with both the disorder in question and the hypothesized causal
factor. That is, the proportion of persons with the disorder hav-
ing the confounding exposure must be different from the pro-
portion of persons without the disorder with the confounding
exposure. It is also necessary that the proportion of those with
the hypothesized causal factor who have the confounding expo-
sure are different from the proportion of those not exposed to
the hypothesized causal factor who have the confounding factor.
For example, a study that found an association between job sat-
isfaction and the risk of occupational back injury could be con-
founded by the physical requirements of work if heavy work was
a risk factor for back injury and was also associated with lack of
job satisfaction in the studied population. Potential confounding
factors can be eliminated in the design of the study by restricted
or matched sampling or, in the data analysis phase, by stratified
or multivariate analysis, for example. If in the study just
described the statistical analyses controlled for physical require-
ments of work or if the researchers conducted an exploratory
analysis and found no association between job satisfaction and
the physical requirements of work, the potential for confound-
ing would be eliminated. In experimental studies, potential con-
founding should be successfully eliminated by truly random
blind assignment of subjects to the different treatments under
study. Comparability of the treatment groups should be con-
firmed by presentation of the baseline characteristics of each
group on entry to the study.
Confounding invalidates a study as a test of the hypothesis.
The studys results cannot be taken as evidence of causality or
efficacy of treatment. Lack of generalizability, as opposed to con-
founding, does not invalidate a studys results but merely
restricts inference to populations similar to those under study.
Chapter 1 Analytic epidemiology 5
Observational study designs are applicable in both clinical
and etiologic epidemiology. In etiologic epidemiology the
researcher tests whether a hypothesized factor is a determinant or
cause of disorder in previously healthy people, whereas in clini-
cal epidemiology one tests whether particular characteristics, risk
factors, or clinical interventions are determinants of the progno-
sis or outcome. The classic observational analytic study designs
are the cohort study, the case-control study, and the cross-sec-
tional study.
Cohort study (Prognostic study)
The cohort study is the observational design that, when well
designed and executed, produces the soundest results in terms of
incidence rates and disorder etiology or prognostic determinants
of all the observational study designs. The hallmark of a cohort
study is that a population initially free of the outcome of interest
is identified and characterized with respect to the hypothesized
risk factor, important covariates, and potential confounders. The
population is observed for a period of time adequate for devel-
opment of the disorder, and the new cases (incident cases) are
recorded. Rates of disorder development are compared between
those exposed and those not exposed to the hypothesized risk
factor.
A study of prognostic factors related to return to work after
episodes of absence due to work-related low-back-pain sickness is
an example of a cohort study. The cohort consisted of all those
first presenting to an occupational health clinic at a large munic-
ipal transportation agency for medical clearance for sick leave
from work because of a complaint of work-related low back pain.
These individuals were asked to complete a questionnaire on
function, pain, satisfaction with work, and beliefs about pain. The
occupational physicians conducting the sickness absence clear-
ance examinations included assessment of gain, posture, and dis-
tribution of painful symptoms specific for back pain. Participants
in the study were followed for 3 months, at which time the
participants return to work status was determined. To identify
which factors best predicted return to work, rates of return to
work were compared between those with high and low scores on
clinical signs and symptoms, function, pain, work satisfaction,
and pain beliefs. Predictors that showed large differences in rates
of return to work were interpreted as being strongly predictive.
12
Cohort studies can be prospective in nature, meaning that a
disorder-free population or group is initially identified and then
subsequently tracked over time (Fig. 1.1). This same model can
also be used with historical records. Employment records, for
example, can be used to identify a group of new employees at a
company. Job status and medical records can then be linked to
these employment records to identify work exposures and the
development of the disorder of interest. Studies that use histori-
cal records are called retrospective.
Loss to follow-up is a potential problem in cohort studies. If
a substantial proportion of subjects are lost to the study for any
reason, for example, having moved out of the region, it would be
expected that fewer cases of the disorder in question would arise
in the study than originally planned. The number of study cases
may ultimately be too small to yield stable estimates of the
incidence rates and, consequently, estimates of the relative risk.
In this case, the observed relative risk would need to be very large
to support the causal hypothesis. For example, consider a cohort
study examining the causal role of occupational repetitive
motion in carpal tunnel syndrome. New workers hired in 1985
through 1990 are enrolled and followed forward for 10 years,
with information on new cases of carpal tunnel syndrome com-
ing from the company medical department records. If 30% of
the workers retire, take disability pensions, die, get another job,
or leave the company for other reasons, there is a substantial loss
to follow-up. A bias in loss to follow-up occurs if the workers
who leave the company are those with the highest exposure to
repetitive work movements and those who leave because upper
extremity problems consistent with preclinical carpal tunnel syn-
drome are making it more difficult for them to do the job. The
observed relative risk is an underestimate of the true relative risk
because the detected incidence of carpal tunnel syndrome among
those with repetitive-motion jobs is lower than the true incidence
and the detected incidence among those not exposed is not
affected. Biased loss to follow-up leading to underestimates of
incidence in the unexposed would produce an inflated observed
relative risk. High proportions lost to follow-up or higher propor-
tions lost in one exposure category than another (selective loss to
follow-up) leave open the possibility of biased loss to follow-up
with consequent distortion of the study findings.
Another form of selection bias can occur. This bias, called
selective survival or selective attrition, occurs when people who
have both the exposure and the disorder have a different proba-
bility of dropping out of the population available to be included
in the study than do people who are not exposed and get the
disorder. This type of bias can easily occur in cross-sectional and
case-control studies. It can also occur in a particular variant of
the cohort study called the prevalent cohort study. For example,
a prevalent cohort study examining occupational repetitive
motion as a risk factor for carpal tunnel syndrome that enrolled
workers who were first employed between 1985 and 1990 and
were still actively employed in 2005 could be affected by selec-
tive attrition if carpal tunnel syndrome by and large developed
within 15 years of employment and workers tended to leave the
company when carpal tunnel syndrome developed.
Target
population
Sample
Risk factor
present
Disease
or
outcome occurs
Disease or
outcome
does not occur
Risk factor
absent
Disease
or
outcome occurs
Disease or
outcome
does not occur
Figure 1.1 Cohort study.
Some diseases or disorders take many years to develop after
the initial exposure to the presumed causal factor or take many
years of exposure. The duration of time between the time of
exposure to the presumed causal risk factor and the development
of disease or disorder is called latency. Another problem concerns
the prevalence of the disorder in the population. If a disorder is
rare, many thousands of subjects may be required to identify and
collect enough cases where the disorder occurs to be suitable for
statistical analysis. Consequently, the cohort study design is not
optimal in situations where the disorder of interest is both very
rare and also has a long latency period. It can be more efficient
in terms of time and the number of subjects studied to address
the hypothesis by means of a case-control study, as described in
the next section.
Case-control study
The essential feature of the case-control study that differentiates
it from the other observational study types is that individuals are
selected for the study on the basis of the presence of the disor-
der in question (cases) and compared with individuals selected
for the study on the basis of the absence of the disorder under
study (control subjects). The presence or absence of the hypoth-
esized causal factor is then ascertained in both case and control
subjects. Although this appears on its face to be a simple under-
taking, case-control studies present a number of methodologic
challenges that must be solved for the study results to be valid
(Fig. 1.2).
A study of ergonomic risk factors for work absence due to onset
of low back painrelated sickness conducted among Baltimore
City workers is an example of a case-control study.
10
Two hundred
cases of absence due to back painrelated sickness were identified
from the citys occupational health department. Four hundred
individuals without back pain but matched on gender, job classi-
fication, and department served as control subjects. In-person
interviews were conducted to collect data on demographics,
work history, psychosocial and work organization characteristics,
and ergonomic factors related to work. Data on these factors
were categorized. To analyze these data, the ratio of those exposed
to the risk factor to those not exposed was calculated once for
those with back pain and again a second time for those without
back pain. A risk factor was interpreted to be associated with
the back pain when the ratio of having the risk factor was higher
among those with back pain as compared with those without
back pain.
Case-control studies frequently suffer from information
biases. For example, if information on exposure to the risk factor
of interest comes from a different source for case and control
subjects, biased exposure information is possible. Recall bias,
in which a case subject is more or less likely to recall an event in
the past than is a control subject, is also possible. There is also
the problem of unbiased recall failure, in which subjects are
asked to recall events or conditions that took place so long
ago they cannot be remembered. Establishing that exposure to
the factor of interest took place long enough before the outcome
to be a biologically plausible determinant is difficult for certain
types of hypotheses; for example, a case-control study examining
preexisting degenerative disk disorder as a determinant of
chronicity (symptom duration greater than 6 months) in workers
with chronic back pain could not establish that the disk problem
predated chronicity based on clinical or imaging examinations at
the time of study. These problems are avoided if the case-control
study uses exposure or prognostic information that was recorded,
for example, in medical or prescription records, long enough
before the disorder condition being studied to be a biologically
plausible cause and to obviate recall problems.
Well-designed and well-conducted case-control studies may
provide evidence as robust as that of cohort studies at consider-
ably less cost and in considerably less time. However, because
of the difficulty in avoiding the problems just described, case-
control studies often produce weaker causal evidence than do
cohort studies.
Cross-sectional study
Cross-sectional studies simultaneously ascertain exposure to
risk factors (or the presence of prognostic factors) and the pres-
ence of the disorder or outcome in question in a population
sampled without regard to the presence of either. This type of
sampling is sometimes called naturalistic sampling. In contrast
to a cohort study, which follows subjects over time and ascertains
incidence, a cross-sectional study ascertains conditions present
at the moment of study, that is, the prevalence of the disorder
or outcome in question at the time of the study. The estimates
of relative risk derived from cross-sectional studies are therefore
estimates of prevalence relative risk. Population-based cross-
sectional studies of low back pain often address, among other
factors, the association of the type of work (occupation, physical
requirements, and so forth) with low back pain (Fig. 1.3).
2
Cross-sectional or survey studies are often undertaken because,
unlike case-control studies, they require few a priori decisions
with regard to the selection of subjects and, unlike cohort
studies, it is not necessary to wait for the study outcome. These
advantages are offset by their susceptibility to some of the prob-
lems of both cohort and case-control studies. When uncommon
Chapter 1 Analytic epidemiology 7
Population
Yes Sample Yes
Disease
present?
Risk Factor
present?
No
Cases
Yes
No
Controls
Yes
No
Sample
Figure 1.2 Case-control study.
Patients
Experimental
treatment
Successes/
Failures
Successes/
Failures
Standard
treatment
Eligible
Ineligible Refuse
Randomize
Agree
Figure 1.4 Randomized control trial.
disorders or exposures are being studied, a large number of people
must be included, as in cohort studies. If information on expo-
sures or on determinants of interest is collected at the time of the
study rather than from previously existing records, there can be
recall biases, recall failure, and problems in establishing the time
sequence of events, just as in case-control studies. Nevertheless,
for relatively common disorders (outcomes) and risk factors
(determinants), cross-sectional studies may be a useful first step
in exploring a hypothesis. Because of their many limitations,
however, cross-sectional studies rarely produce robust results for
evaluating the importance of causal or prognostic factors.
When the literature on a problem consists predominantly of
cross-sectional studies, it is often the case that the analytic epi-
demiology of that problem is in its infancy. Until recently, much
of the epidemiologic information on occupational low back pain
was derived from descriptive and cross-sectional studies.
16
In the
past 5 or 6 years there has been a substantial advance in the quan-
tity and quality of observational analytic studies of work-related
back pain. The epidemiologic investigation of upper extremity
disorders began later than that of low back pain. Consequently,
knowledge of the risk factors for work-related upper extremity
disorders is less developed. The intrinsic strengths and limita-
tions of the basic observational study designs are summarized in
Table 1.1.
Experimental study designs: clinical trials
The distinction between observational and interventional study
designs is that in observational designs the investigator does not
cause the exposure to the causal factor or treatment for the pur-
poses of the study, whereas in interventional designs the investi-
gator does cause subjects to be exposed to different factors or
treatments. Observational study designs are susceptible to treat-
ment assignment biases in which the treatment the patients
receive is influenced by certain patient characteristics (e.g., life-
style or clinical severity) that can confound the results. Clinical
trials, in which the treating physicians or the investigators con-
trol which treatment patients receive, are also susceptible to such
biases. For this reason, randomized controlled trials, where only
chance influences which treatment eligible patients receive, are
the preferred method of evaluating therapeutic interventions.
The validity of randomized controlled trials depends on all
the methodologic features described for the observational study
designs and more. The study must be confined to those patients
who have agreed to participate. Comparisons of treatment out-
comes in patients who agree to participate with those in patients
who refuse to participate are not valid. Assignment of patients to
treatments must be done by using accepted methods of random-
ization, which are described in the report, and the resulting com-
parability of the treatment groups on important covariates
should be described, usually in a table summarizing the baseline
characteristics of the treatment groups. On the occasions when,
by chance, randomization does not result in comparable groups,
potential confounding must be controlled in the statistical analysis.
Figure 1.4 is a schematic representation of appropriate design in
a randomized controlled trial.
Ordinarily, in randomized trials the treating physician and
the patient are blind to which treatment group the patient has
been assigned. If this is not possible, assessment of the study
Study
population
Risk factor present
disease present
Sample
Risk factor present
disease absent
Risk factor absent
disease present
Risk factor absent
disease absent
Figure 1.3 Cross-sectional study.
Table 1.1 Strengths (+) and limitations (-) of the
observational study designs
Case- Cross-
Cohort Control Sectional
Feature Study Study Study
Selective Survival + +
Recall bias +
Loss to follow-up + +
Time sequence of events +
Time to complete + +
Expense + +/
outcome should be done by an independent evaluator to avoid
observer and participant biases in assessing the outcome. This is
particularly important when the outcome being assessed is
subjective. Information should be collected in the same way
and with the same frequency in all treatment groups. Eligibility
and exclusion criteria should be described and be appropriate to
the question being addressed. Treatments should be clearly
described, and patient compliance, dropouts from the study,
and complications should be described and equivalent in both
groups.
Finally, the outcomes studied should be appropriate to the
treatment or condition in question. A number of general health
status assessment measures are used, for example, the SF-36,
a standardized multidimensional assessment instrument that
includes functional capacity, pain, locomotion, mental status,
and affect. There are numerous assessment instruments for back
pain disability, including the Oswestry,
5
the Roland-Morris ques-
tionnaire,
15
the Quebec Back Pain Disability Scale,
8
the Maine-
Seattle back pain disability questionnaire,
1
and others.
3
STATISTICAL ISSUES
Methods of analysis
The statistical analysis of any study result should be appropriate to
the hypothesis and to the structure of the data collected. When,
for instance, the study examines the difference in Oswestry
scores associated with a conditioning program as compared with
usual care for subacute low back pain, comparisons of the mean
scores in the treatment groups may be appropriate. If it is neces-
sary to control for pretreatment differences between the groups,
the analysis uses multivariate methods such as analysis of covari-
ance or multiple regression. Occasionally, because of the statistical
characteristics of the outcome being assessed, it may be necessary
to transform it (e.g., log transformation, square root transforma-
tion) and analyze the transformed variable. It is often the case
that the outcome variable distribution or the conditions of the
study do not conform to the requirements of the usual statistical
hypothesis tests such as t-tests, analysis of covariance, and regres-
sion analysis. In these cases, a nonparametric method of statisti-
cal analysis such as the Wilcoxon method is appropriate.
When the hypothesis addresses the relative frequency of an
event such as a back injury rate, a ratio can be formed consisting
of the risk of development of the disorder among those exposed
to the risk factor compared with the risk of the disorder among
those not exposed to the risk factor. This ratio is called a relative
risk. When the relative risk is 1, then the risk of the disorder is
the same among those exposed to the risk factor as those not
exposed. However, when the relative risk diverges from 1, then
the risk is not the same between the exposed and unexposed
groups. This is interpreted as evidence for an association between
the risk factor and the disorder. The relative risk may be adjusted
for important covariates or to eliminate potential confounding.
Relative risks can be calculated only in those studies where the
entire study population is tracked or a representative sample is
identified, as would be the case in a cohort study.
A relative risk cannot be calculated in situations where the
study sample is not representative (e.g., as would be the case in a
case-control study). Instead, an alternative to the relative risk needs
to be used. The odds ratio is a measure of association that, in cer-
tain circumstances, can be used to estimate relative risk. The odds
ratio is the ratio of the odds of the disorder in those exposed to
the odds of the disorder in those unexposed. It also has valuable
statistical properties because it can be estimated by using logistic
regression. The effects of confounding variables can be controlled
or the simultaneous effects of several causal variables or covariates
can be estimated by using multiple logistic regression.
Another measure of association can be found in studies that
examine the rate of the development of a disorder in a population
over time. In these studies, the risk of developing a disorder within
a cohort changes for each point in time. As members of the cohort
develop a disorder, the total number of individuals in the cohort
still free of the disorder becomes smaller and the calculation of
risk changes. A survival curve shows the cumulative proportion of
cohort members remaining free of the disorder on the vertical axis
and time on the horizontal axis (Fig. 1.5). Typically, survival curves
show an exponential relationship between cumulative proportion
remaining free of the disorder and time. We can examine whether
the survival experience is different between members of a cohort
with different exposure profiles by using statistical tests specific for
this type of analysis, such as the log-rank test.
9
Hazard is a term that expresses the rate of change of the
cumulative proportion surviving with time. In prognostic studies
it is possible to compare whether the rate of change of survival
(hazard) is different between exposure groups. A useful property
of hazards is that this term can be modeled using logistic regres-
sion techniques. The Cox proportionate hazards model is used
to evaluate differences in hazard between exposure groups. The
hazard ratio is interpreted much like the relative risk or odds
ratio. When the hazard ratio is equal to 1, then the survival expe-
rience is interpreted to be the same among exposure groups.
When the hazard ratio is not equal to 1, the interpretation is that
there is an association between exposure to the risk factor and
survival experience related to the disorder of interest.
9
An advantage of survival analysis is that all study subjects con-
tribute information for as long as they remain in the study. The
reader should be aware, however, that if the number of dropouts
during the course of the study is substantial, estimates of the
hazard ratio toward the end of the follow-up period are based on
relatively small numbers and are consequently unstable.
Estimates and confidence limits
Research is conducted on a sample of persons or other units of
observation drawn from a target population. The results of any
given study are estimates of the true means, proportions, relative
risks, and so forth in the population from which the samples were
drawn. The precision of a study estimate of the population value,
or parameter, of a measurement is described by the standard
error of estimate. The standard error (SE) is the square root of the
ratio of the variance (s
2
), or variability of the measurement in the
sample, to the number of subjects (N) in the study. For example,
SE
mean
=
s
N
2
Chapter 1 Statistical Issues 9
Variance is affected by a number of factors, including
interindividual variability, intraindividual variability (such as diur-
nal variations), and instrument variability. Designing or executing
a study to reduce any of these components reduces the variance of
the measurement, thus reducing the standard error and increasing
the stability of the estimate of the population parameter. The
larger the number of subjects on whom the estimate is based, the
smaller the standard error and the more confident we can be in its
representation of the population parameter.
Because sample results are estimates of population parameters,
it is increasingly becoming the standard of reporting to describe
the precision of the estimates as a range within which the popu-
lation parameter probably lies. This is the confidence limit
around the estimate and is by convention expressed as the 95%
confidence limit. For example, the 95% confidence limit for a
mean is approximated by
95% confidence interval = mean 2(SE
mean
)
Statistical hypothesis testing
Because there is always sampling error, estimates may be
expected to vary from sample to sample. Consequently, study
results must be subjected to statistical hypothesis testing; that is,
study results must be tested to determine the probability that the
observed results from a specific study could have occurred by
chance alone.
The statistical hypothesis test evaluates the null hypothesis
that the observed study results occurred because of sampling
error when there was no true association in the population from
which the study subjects were sampled. The probability of mak-
ing this type of error is designated as alpha (). If the observed
association is large enough that this kind of error is improbable,
the null hypothesis is rejected. The investigators then accept the
alternative hypothesis, that the observed estimates of relative risk
or differences between treatments reflect the true situation in the
population from which the samples were drawn. By convention,
the cutoff for rejecting the null hypothesis is usually set at 0.05.
Then if the probability (p value) that the observed results are due
to sampling error is less than 0.05, that is, less than , the null
hypothesis is rejected and the results are declared statistically signif-
icant. Thus, statistically significant results are simply results that
we have decided, within an acceptable margin of error, probably
did not occur by chance. Further, the larger the observed associ-
ation relative to the underlying variability of the outcome being
measured, the more likely that it will be declared statistically
significant.
Statistical power and sample size
Statistical hypothesis tests actually involve two probabilities. The
probability of making a type I error by incorrectly rejecting the
null hypothesis, that is, by declaring an observed association to
be statistically significant when in fact it is the result of sampling
error, is referred to as , as described in the preceding paragraph.
There is also the probability of incorrectly accepting the null
hypothesis; that is, declaring that the study results are due to
sampling error (not statistically significant) when in fact they
reflect a true association in the population from which the study
subjects were drawn. This is the type II error and its probability is
beta (). The complementary probability that a study will be able
to correctly reject the null hypothesis when it is false, that is,
correctly detect an association when there is one in the popula-
tion at large, is referred to as statistical power (1 ). Table 1.2
illustrates the different conditions and possible results of a statis-
tical hypothesis test.
In the planning phase of research the investigators should
make a determination of how strong an association would be
clinically significant, that is, how large an estimated relative risk
100%
75%
50%
25%
0 90 180 364 270
0%
P
e
r
c
e
n
t

r
e
t
u
r
n
i
n
g

b
a
c
k

t
o

a
n
y

w
o
r
k
Time lost from work because of LBP (in days)
No restrictions
Some restrictions
Figure 1.5 Return to any work from
sick absence because of nonspecific
low back pain (n = 225). (From Hiebert
R, Skovron ML, Nordin M: Work
restrictions and outcome of nonspecific
low back pain. Spine 28(7): 722-728,
2003. Reprinted with permission.)
or how big a difference between treatments. Because the validity
of the study requires that it be a true test of the research hypoth-
esis, it is important to design the study so that a clinically signif-
icant association will have a good chance of being declared
statistically significant, that is, so that the study has sufficient
power to detect a clinically significant association. The larger the
sample size, the more power the statistical test has to detect asso-
ciations; in other words, as expected differences or relative risks
get smaller, the number of subjects studied must increase to have
adequate power to test the hypothesis. Conversely, with very
large numbers of study subjects it is possible to declare trivial
associations statistically significant. When studies with small
sample sizes report results that are not statistically significant,
they should also report how large an association would have
been required for there to have good power to detect it. The
reader should also evaluate whether the observed difference and
its upper confidence limit, although not statistically significant,
are clinically significant. When studies with huge numbers of
subjects report statistically significant results, the reader should
decide whether the differences are trivial in clinical terms, even
though they are statistically significant.
SUMMARY
The validity of clinical research depends on a number of factors.
The hypothesis must be formulated specifically enough to be
testable. The appropriate study subjects should be eligible, and
there should not be differential participation. The information
collected should be appropriate to the hypothesis and accurate.
The study design and information sources should avoid potential
information biases. Potential confounders should be eliminated
in the study design or controlled in the statistical analysis. At the
time the study is designed, a clinically significant hypothesized
result should be specified, the plan of statistical analysis deter-
mined, and the necessary number of study subjects defined.
Study management should avoid the introduction of differential
loss to follow-up, unblinding, and other potential problems. The
statistical analysis should be appropriate to the structure of the
data and to the hypothesis. Finally, although the discussion
should place the study in the context of other work and what is
already known about the question, the specific conclusions
should not go beyond what was actually tested.
REFERENCES
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Maine-Seattle back questionnaire: a 12-item disability questionnaire for evaluating
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cohort analysis. Spine 28(16):1869-1876, 2003.
2. Bernard BP, ed: Musculoskeletal disorders and workplace factors: a critical review
of epidemiologic evidence for work-related musculoskeletal disorders of the neck,
upper extremity, and low back. U.S. Dept. of Health and Human Services, Public
Health Service, Centers for Disease Control and Prevention. Cincinnati, OH, 1997,
National Institute for Occupational Safety and Health.
3. Bombardier C: Outcome assessments in the evaluation of treatment of spinal
disorders: summary and general recommendations. Spine 25(24):3100-3103,
2000.
4. Bureau of Labor Statistics, US Labor Department, Annual Survey 2003,
Tables R19, 22.
5. Fairbank JC, Pynsent PB: The Oswestry Disability Index. Spine 25(22):2940-2952;
discussion 2952, 2000.
6. Gyntelberg F: One-year incidence of low back pain among male residents of
Copenhagen aged 40-59. Danish Med Bull 21:30-36, 1974.
7. Kelsey JL, Thompson D, Evans AS: Methods in observational epidemiology. New York,
1986, Oxford University Press.
8. Kopec JA, Esdaile JM, Abrahamowicz M, et al: The Quebec Back Pain Disability Scale:
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9. Lee E: Statistical methods for survival data analysis. Belmont, CA, Lifetime Learning
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11. National Research Council and the Institute of Medicine. Musculoskeletal disorders
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12. Nordin MN, Skovron ML, Hiebert R, et al: Early predictors of delayed return to work in
patients with low back pain. J Musculoskel Dis 5(2):5-27, 1997.
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practice. Spine 20:318-327, 1995.
14. Praemer A, Furner S, Rice DP: Musculoskeletal conditions in the United States.
Rosemont, IL, 1999, American Academy of Orthopaedic Surgeons.
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141-144, 1983.
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Chapter 1 References 11
Table 1.2 Population conditions, statistical
hypothesis test results, error types, and designations
Hypothesis
Test Result Population Condition
Accept null hypothesis NULL HYPOTHESIS TRUE NULL HYPOTHESIS FALSE
No association NO ASSOCIATION ASSOCIATION EXISTS
Correct Type II error (beta)
Reject null hypothesis Type I error (alpha) Correct
Association exists
C HA P T E R
Psychosocial Aspects of
Work-Related Musculoskeletal
Disorders: Clinical Implications
Sherri Weiser
Until recently, attempts to unravel the mystery of work-related
musculoskeletal disorders (MSDs) concentrated on the physical
demands of the job and the physical vulnerabilities of the
worker. It became clear that this problem did not easily lend
itself to reductionistic approaches. Although certain physical
loads and tasks have been associated with the development
of musculoskeletal problems, the strength of these associations
has been disappointingly weak.
29
Furthermore, a determination
of physical vulnerability before injury is nearly impossible. Even
when a physical defect such as disk herniation has been estab-
lished in conjunction with a report of pain, the correspondence
with actual disability is often low.
Like all human conditions, MSDs can be infinitely complex.
A thorough understanding of these disorders requires a consid-
eration of influences beyond the physical. The workers psycho-
logic attributes and social reality may have significant bearing
on the onset, progression, and outcome of occupational MSDs.
A biopsychosocial perspective offers much in the way of under-
standing these disorders.
Adoption of the biopsychosocial model in pain and disability
research has resulted in the identification of specific psychologic
and social aspects of MSDs. Recently, this research has been
summarized in a number of excellent review articles and treat-
ment guidelines, conclusions from which are discussed. The
biopsychosocial model implies not just the inclusion of psycho-
logic and social considerations but a new perspective on the part
of all stakeholders involved in the prevention and treatment of
MSDs. This chapter describes how to achieve the goal of pre-
venting and treating the disorder in practical terms.
THE BIOPSYCHOSOCIAL MODEL
The notion of a link between the mind and body has existed
throughout history. It was Walter Canon,
2
however, who sub-
stantiated this idea with his scientific explanation of the fight or
flight response. His research identified the organisms physical
reactions to psychologic stress. Selye
24
later showed how these
responses, if left unchecked, can over time cause severe damage
to vulnerable organs and body systems and may even cause
death. Today, the relationship between the mind and the body
is studied extensively. Psychologic factors have been shown to
affect a spectrum of diseases involving virtually all bodily organs
and systems.
8
First described by Engel in 1977,
5
the biopsychoso-
cial model extends beyond mind and body to include the impact
of social factors on illness. Influenced by models of stress and
illness, Engel concluded that any illness must be viewed from a
multidimensional perspective that takes biologic, psychologic,
and social factors into consideration.
5
Furthermore, these factors
are not independent, as a medical model would suggest, but
interrelated. It was by understanding this perspective, Engel
believed, that physicians would be prepared to take on the
complexities of health and illness.
The biopsychosocial model soon became the prevailing view
among those involved in pain research. In 1965 the gate control
theory outlined the channels of pain transmission through
neurologic pathways.
19
This theory further asserted that pain
transmission may be modulated by cognitive and affective states.
This model was fundamental in explaining the disparities
between physical findings and the phenomenologic experience
of pain. The gate control theory laid the groundwork for modern
approaches to treating chronic pain.
In 1992, Waddell
28
presented a detailed analysis of low back
pain with the use of a biopsychosocial model (Fig. 2.1). The many
levels on which pain is experienced are defined in the model. The
physical injury is interpreted cognitively, resulting in a corre-
sponding emotion. A man who believes that he has a herniated
disk, for example, is more apt to be anxious and depressed than
a man who believes that he has a sprain. The man with the her-
niated disk may also display more avoidance behavior initially
than the man who believes he sprained his back. This process
takes place within a social context that is constantly providing
feedback and modifying the individuals response.
Waddell also pointed out that feedback loops exist among all
levels in the model and that a change in one component affects
the others. If the man with the supposed herniation sees a physi-
cian and is assured that the problem is only a sprain, his belief
has changed. As a result, his affect and pain behavior will change,
2
and nociception may be experienced as less severe. These feed-
back loops are particularly important in chronic low back pain,
wherein the original injury is often resolved. In these cases, psy-
chologic and social variables are even greater determinants of
functional status than in cases of acute back pain when nocicep-
tion is responsible for much of the illness behavior.
Occupational musculoskeletal injuries are clearly amenable to
biopsychosocial analysis. They either occur at work or are
believed to be its result. The cognitive, affective, behavioral, and
social elements of such an injury are therefore inextricably related
to the workplace. Injuries or disorders that did not occur at work
may also be considered work-related if attitudes or beliefs about
work affect recovery. If an injured worker fears that returning to
work will exacerbate an injury, for example, recovery may be
delayed.
Recently, a number of studies have demonstrated the impact
of psychologic and social factors on occupational musculoskele-
tal injuries. What has emerged is evidence that these factors have
as much, and in some cases more, predictive value as physical
and environmental factors.
The main findings from recent critical review articles and cur-
rent studies are discussed below. Most of the articles refer to non-
specific disorders of the spine; research has centered on these
conditions because they account for most of the associated costs
and suffering caused by the disorder. Some reviews include the
upper extremities as well. To date, no high quality study of work-
related lower extremity injuries that explores psychosocial factors
has been found.
PSYCHOLOGIC AND PSYCHOSOCIAL
FACTORS ASSOCIATED WITH MSDs
Psychologic factors refer to cognitions or beliefs about pain and
disability and affective or emotional responses, whereas psy-
chosocial factors reflect an individuals perceptions of others and
the environment. Recent systematic evidence-based reviews have
concluded that even when measured early in the injury, both
these factors are stronger predictors than physical factors of out-
comes such as work status.
The Clinical Guidelines for the Management of Acute Low
Back Pain, published in 2001, state that in addition to social and
economic factors, psychologic factors play an important role in
the development of chronic low back pain and disability and
influence a patients response to treatment and rehabilitation.
30
Specifically, beliefs that activity and work will make pain worse
(fear-avoidance beliefs) and that the patient is not responsible for
the pain or treatment along with behaviors intended to commu-
nicate that the patient is in pain (illness behaviors) are associated
with poor outcome.
Using strict inclusion criteria, in 2001 Koes et al
13
published
a comparison of clinical guidelines for the management of low
back pain from 11 different countries that appeared from 1994
until 2000. They found that in most regards the content of the
guidelines appeared to be quite similar and that all recognized
the importance of psychologic and psychosocial factors, includ-
ing work perceptions, in the development and maintenance of
low back pain.
Indeed, the New Zealand Guidelines for assessing acute low
backpain, updated in 2003, likewise finds good agreement that
beliefs, mood states, and behaviors, such as those identified by
Waddell et al,
29
consistently predict poor outcome.
21
One of
these is the belief that work will make the pain worse, evidence
for which is so compelling that investigators have labeled this
risk factor one of the yellow flags. Yellow flags are defined as
factors that may increase the risk of developing or perpetuating
long-term disability and work loss associated with low back pain.
The New Zealand group recommends their assessment as early as
2 weeks after injury.
Occupational health guidelines for low back pain were pub-
lished in 2001. Although the effect size was small, strong evi-
dence was found that psychosocial factors are associated with the
risk of onset of low back pain in symptom-free workers. In the
workplace, psychosocial factors are stronger predictors of care
seeking and disability than clinical symptoms or physical work
demands. Specifically, negative work perceptions were risk fac-
tors for symptom reports, health care utilization, and work loss.
The most important factors associated with delayed recovery and
response to treatment were beliefs that work caused the pain and
expectations about recovery.
29
A comparison of international
occupational low back pain guidelines shows them in complete
agreement that the early assessment of these risk factors was
important if the patient exceeds the expected recovery time.
25
Other reviews of factors affecting low back pain outcomes
show similar results but call for more stringent scientific investi-
gation of the interrelationships. For example, Hoogendoorn
et al
10
reviewed the literature and found that low workplace
social support and low job satisfaction were related to reports of
Chapter 2 Psychosocial aspects of work-related musculoskeletal disorders 14
Figure 2.1 A cross-sectional analysis of the clinical findings and
assessment of low back pain and disability at one point in time. (From
Waddell G: Biopsychosocial analysis of low back pain. In M Nordin,
TL Vischer, eds: Common low back pain: prevention of chronicity.
London, 1992, Bailliere Tindall.)
Sensory
Cognitive
Affective
Illness behavior
Social environment
back pain, but most studies failed to adjust for psychosocial work
characteristics and physical load at work. Crook et al
4
deter-
mined from their review that among other factors, psychologic
distress and work environment characteristics were important
prognostic factors. They noted, however, that most studies failed
to investigate interactions among psychologic, social, and physi-
cal variables.
Likewise, Pincus et al
23
noted a lack of rigorous prospective
studies that evaluated the role of psychologic factors in the
development of chronicity. Of 25 publications, only 6 met their
acceptability criteria for review. Depression, distress, and to a
lesser extent somatization were the psychologic factors most
strongly linked to low back pain disability. Catastrophizing by
disabled workers as a coping strategy received weak support. The
role of coping in conjunction with psychologic factors remains
unclear.
Although there are fewer studies on upper extremities than on
back pain, thus far similar factors seem to be related to both disor-
ders. In another review article, higher levels of perceived job
demands and stress were the psychosocial factors most consistently
linked to upper extremity disorders. Epidemiologic reviews
revealed also that psychosocial factors unrelated to work, such as
general worry/psychologic tension, depression/anxiety, general
coping style, and response to pain, are likewise associated with
both back and upper extremity disorders.
15
Systematic reviews
on this topic have not, however, been conducted.
An interesting study by Ijzelenberg et al
11
investigated
whether individual, work-related physical, and psychosocial risk
factors involved in the occurrence of musculoskeletal complaints
also determined musculoskeletal sickness absence. Using a cross-
sectional study design and self-administered questionnaire, inves-
tigators collected data on individual and work-related risk factors
and the occurrence of musculoskeletal complaints and muscu-
loskeletal sickness absence among 373 employees of laundry-works
and dry-cleaning businesses. Results show that both work-related
physical factors and psychosocial factors showed strong associa-
tions with low back pain and upper extremity complaints. Work-
related physical factors did not influence sickness absence,
however, whereas psychosocial factors showed some associations
with it. This finding supports the notion that illness behaviors
such as work absence are modified by cognitive and affective
responses to physical symptoms in neck and back disorders.
Linton
15
systematically reviewed numerous studies of variable
methodologic quality that looked at the effects of various psy-
chologic factors on neck and back pain and concluded that there
is a clear link. Prospective studies indicate, furthermore, that psy-
chologic variables are related to the onset of pain and to all of its
phases: Certain factors such as distress, anxiety, cognitive func-
tioning, and pain behavior were found to be significant at all
stages from acute to chronic pain. Still, psychologic factors
account for only a portion of the variance, underscoring the
importance of a multidimensional view.
Luo et al
16
found a variety of factors, including general stress,
depression, and anxiety, to be associated with neck pain disability.
Carroll et al
3
confirmed the role of depression as a risk factor for
pain onset. They followed a population-based random sample of
adults and assessed them at 6 and 12 months. Controlling for
demographic and socioeconomic factors, health status, comor-
bid medical conditions, and injuries to the neck or low back,
they found an independent and robust relationship between
depressive symptoms and onset of a pain episode. They con-
cluded that depression is a strong and independent predictor for
the onset of an episode of intense and/or disabling neck and low
back pain.
WHAT IS THE RELATIONSHIP BETWEEN
PSYCHOSOCIAL FACTORS AND
WORK-RELATED MSDs?
There are a number of ways to explain the effect of psychosocial
factors on MSDs. Perhaps the most straightforward explanation
is that workers who are depressed or dissatisfied at work simply
report more symptoms and disability than those who are content
at their jobs. Distress in life and work may cause extra attention
to be paid to symptoms, and therefore the signs are experienced
as more troubling. This does not imply that workers are inten-
tionally making more of symptoms than is warranted but that
they are more likely to notice symptoms that can distract them
from their daily routines.
Another popular explanation is that stress results in increased
muscle tension, causing spasms and ischemia, a painful condi-
tion resulting from oxygen reduction and the release of pain-
producing chemicals. Over time this pain may cause more distress,
leading to a chronic cycle of stress and pain. Some laboratory
studies have demonstrated an increase in muscle activation
under stress,
18
but findings have been inconsistent among patients
with chronic pain. This may be because stress-induced muscle
tension has a role in the development of chronic pain, but once
patients are chronic their reactivity to stress becomes altered in
ways that are unclear at present.
The National Research Council and the Institute of Medicine
reviewed evidence for the relationship between psychologic and
physical factors and concluded that data exist to support a direct
role of the central nervous system.
20
This may help to explain
how psychologic processes such as attention and emotion influ-
ence pain and its tolerance, an explanation supported by studies
showing that pain is linked to a tendency to somatize or focus
on symptoms.
17
Other theories mentioned in the review include physiologic
changes that occur under stress and result eventually in muscu-
loskeletal pain. Stress hormones may facilitate the transmission
of painful stimuli; physically stressful work tasks are associated
with an increased release of stress hormones and slower recovery
times. One reason for this may be that stress hormones affect the
health of muscles, tendons, and ligaments and impede inflam-
matory or immune responses.
Other factors such as behavior or life-style may moderate the
effects of stress on muscle tension and biochemical changes. The
concept of work style has been proposed to define how indi-
viduals interact with work demands.
6
Originally proposed to
explain work-related upper extremity disorders, work style is
defined as cognitive, behavioral, and physiologic components of
the stress response expressed behaviorally in movement, posture,
and activity. Workers who respond to physical or psychologic
workplace demands with a high-risk work style display excessive
attempts to cope with stress and are susceptible to its negative
Chapter 2 What is the relationship between psychosocial factors and work-related MSDs 15
consequences such as continuous arousal or reactivity. Similarly,
Marras et al
18
found that characteristic ways of responding to the
environment were predictive of spinal loading. During a lifting
task, introverts tend to exhibit muscle coactivation and alter-
ation in movement patterns higher than those of extroverts.
Stress-related behaviors such as these have been linked to symp-
tom severity, functional limitations, and work disability.
9
It is clear that the relationship between psychologic distress and
physical responses is not simple. More research is needed to
develop detailed models of the stresspain relationship. Although
various pathways have been proposed, there is a need to under-
stand causal pathways and interactions among stresses and
responses. Most likely there is no simple explanation of this rela-
tionship, and these proposed pathways are not mutually exclusive
but work together in an ongoing dynamic way to result in MSDs.
It is possible also that the stress pathways discussed here have vari-
able influences in different stages of pain. What began as pain
related to muscle tension, for instance, may over time develop
into neuropathic pain. In addition, more clarity is needed in defin-
ing outcome measures, because different factors may moderate
stress and physical complaints, sick absences, and disability.
PSYCHOSOCIAL INTERVENTIONS FOR MSDs
Most individuals at risk for MSDs can be effectively managed by
their usual treatment provider, without the need for referral to a
psychologist. Appropriate information and advice from the
physician can reduce anxiety and improve patient satisfaction
with care. Every encounter with health care professionals and
medical management systems provides an opportunity for inter-
vention. Waddell
28
astutely observed the powerful effects a
physician can have on the patient. Information that is vague,
incomplete, or incomprehensible to a lay person can render the
patient confused, helpless, and afraid. In the mind of a patient,
the diagnosis of a herniated disk, for example, can be a sentence
to disability. Diagnostic film results are often held up as proof by
patients fearful of permanent disability. It is the health care
providers responsibility to explain the implications of any diag-
nosis in terms the patient can understand. In the case of disk her-
niation, the patient needs to know that pain and disability are
often self-limiting and that many people with this condition
maintain their usual life-styles.
Making sure that the patient has a realistic picture of the diag-
nosis and the prognosis is the first step. Patients who seem overly
distressed can be questioned about other life circumstances.
When the injury is work related, questions about work are partic-
ularly important. Often, patients feel residual anger toward the
employer, sometimes believing that it is the employers respon-
sibility to make sure they get well. Even if not responsible for
their injuries, patients who understand the normal course of low
back pain and are encouraged to take responsibility for their
recovery from the onset may be spared the ordeal of becoming a
compensation failure.
Primary health care professionals have a responsibility also to
make appropriate referrals. Information given by the physician
can be reinforced or contradicted by secondary caregivers. One
of the major causes of distress, contradictory information can
lead to endless doctor shopping and prolongation of recovery.
Physicians should share with distressed patients information
about treatment philosophies and their possible outcomes.
At the very least, physicians should be aware of the treatment
philosophy of any facility to which they are referring patients,
ideally one that adheres to current guidelines for the treatment
of acute low back pain.
The occupational health guidelines for the management of
low back pain summarize recommendations for physicians to
minimize the likelihood of chronic problems
29
:
Reassure the worker and provide adequate information about

the self-limiting nature and good prognosis of lower back pain.
Advise the worker to continue normal activity and work or

to return to them as soon as possible, even if there is still
some pain.
Because most workers with lower back pain manage to return

to more or less normal duties quite rapidly, consider tempo-
rary adaptations of work duties or hours only when necessary.
If a worker fails to return to work within 2-12 weeks (different

guidelines vary considerably about the time scale), refer him
or her to a gradually increasing exercise program or multidis-
ciplinary rehabilitation (exercises, education, reassurance, and
pain management following behavioral principles). These
rehabilitation programs should be embedded in an occupa-
tional setting.
Based on the conclusion that active care is superior to passive ther-
apy, treatment guidelines recommending active and goal-oriented
physical therapy should be the first course of treatment. Research
has shown that the specific type of exercise prescribed is less
important that the overall therapy philosophy. The objective
should be to increase gradually the individuals capacity for work
with a balanced strength, flexibility, and cardiovascular program.
Specific goal setting ensures that improvement is monitored,
whereas positive feedback rewards productive behavior. The easiest
program to implement early in treatment, a behavioral approach
pioneered by Fordyce,
7
consists of time-contingent care in which
medication levels, exercise goals, and duration of treatment are
preset and not determined by the patient. The idea is to provide
environmental contingencies that reinforce well behavior and
ignore pain behavior. In a benchmark study, Fordyce
7
com-
pared this approach with traditional care in which patients were
told to let pain be your guide. Subjects with back pain for less
than 10 days were randomly assigned to one of the two proto-
cols and were followed at 6 weeks and 9 to 12 months after treat-
ment. Although no differences were noted at 6 weeks, long-term
follow-up showed significantly greater improvement in function-
ing for the treatment group.
Like MSDs, physical therapy may be viewed from a biopsy-
chosocial perspective. In contrast to passive modalities, an active
approach shifts the responsibility to patients and provides tech-
niques that they can use themselves to maintain fitness. As such,
it increases the patients sense of control and may be instrumen-
tal in changing negative beliefs about pain. With improvement,
the patients fears of returning to work should subside.
After 2 weeks, patients who are not achieving weekly goals
should be referred for a psychosocial evaluation. If warranted,
they can begin a multidisciplinary program that addresses psy-
chosocial issues. By their very nature these types of programs
address physical, psychologic, and social concerns simultaneously.
Figure 2.2 Application of the biopsychosocial model: general guidelines for primary health care providers.
A multidisciplinary approach in treating patients with chronic
pain is fairly standard,
31
but the application of a biopsychosocial
model in the acute and subacute phases of treatment as well is
gaining popularity.
EVIDENCE
No randomized controlled studies have assessed the use of
psychologic interventions alone for MSDs, and high-quality
studies that assess the effectiveness of multidisciplinary care for
occupational MSDs in general are few. Nonetheless, in line
with international opinion, expert panels have recommended
the use of multidisciplinary team management for episodes of
acute low back pain that is unresolved between 2 and 6 weeks,
when patients risk chronic disability.
Evidence clearly shows that multidisciplinary teams or net-
works are effective in managing chronic back pain,
14,22,27
but their
effectiveness for returning chronic patients to work remains
unclear. Some studies showed good outcomes for chronic low
back pain patients who are highly motivated to return to work,
1
but randomized trials have yet to be done.
Chapter 2 Evidence 17
Onset of pain
Explain the biopsychosocial model
Address concerns about pain, including
the course, diagnosis, and prognosis
Emphasize the patient's role in recovery
Make appropriate referral if indicated
Four weeks after
Address concerns again, old and new
Address social factors again
Reinforce patient's role in recovery again
Refer for multidisciplinary evaluation
and possible treatment
Seven weeks after
Address concerns again
Address social factors again
Reinforce patient's role in recovery
Refer for multidisciplinary evaluation
and treatment
Two weeks after
Address concerns again, old and new
Address social factors including attitudes about work,
as well as family and friends' responses to pain
Reinforce patient's role in recovery again
Make appropriate referral if indicated
Karjalainen et al
12
conducted a Cochrane review of multidisci-
plinary programs for subacute low back pain patients. They con-
cluded that there is moderate evidence of positive effectiveness
of multidisciplinary rehabilitation for subacute low back pain and
that a workplace visit increases the effectiveness. This endorsement
is guarded because the only two articles that fit their inclusion
criteria were only of moderate quality. However, more support
for this treatment in the subacute phase was provided by van den
Hout et al.
26
In a randomized study, they showed that adding
training in problem solving to a graded activity program
improved outcome.
The Work Loss Data Institute considered but did not recom-
mend multidisciplinary or cognitive-behavioral treatment for
upper extremity pain due to lack of studies.
32
New studies should
consider other MSDs as well. Future research would benefit also
from a comprehensive multivariate causal model that would
allow the assessment of interactions among psychologic, social,
and physical variables. Adjustments for workload could be made
when studying the effects of other factors; such a model would
also permit an understanding of how these risk factors emerge
during the transition from acute to chronic problems.
SUMMARY
Traditional treatments for occupational MSDs have fallen short
of expectations. The biopsychosocial model goes beyond physi-
cal factors to include psychologic and psychosocial elements that
affect the worker before and after an injury. Investigations into
the practical application of this model are most convincing.
Studies have shown that psychosocial factors are at least as impor-
tant as and often more important than physical factors in deter-
mining disability. Programs that have attempted to prevent
injury or chronicity associated with occupational low back pain
have flourished when they include a biopsychosocial framework.
Though more research is needed, it is suggested that our best
option is for primary health care providers and all health care
practitioners to apply a biopsychosocial model in the same fash-
ion for all MSDs that do not respond to traditional care (Fig. 2.2).
Because we all share the burden of disability, we must all share in
the solution. Much can be done by all medical professionals to
make this process easier and more successful for everyone. For
physicians, establishing a good rapport with the patient, giving
clear and intelligible information, encouraging an active approach
to treatment, and making appropriate referrals at the first sign of
delayed recovery can go a long way toward reducing occupa-
tional MSDs. Physical therapists can follow a behavior model of
active care that encourages patient responsibility for outcome
and reinforces function over pain.
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32. Work Loss Data Institute: Disorders of the neck and upper back. Occup Environ Med
60:618-626, 2003.
C HA P T E R
Neck
3
A Review of the
Epidemiology of Neck Pain
in Workers: Prevalence,
Incidence, and Risk Factors
Pierre Ct, Linda Carroll, J. David Cassidy, Mana Rezai, Vicki Kristman,
and the Scientific Secretariat of the 2000-2010 Bone and Joint Decade
Task Force on Neck Pain and Its Associated Disorders*
In the past half century, the nature of work has rapidly changed.
Once dependent mainly on manufacturing and resource extrac-
tion, the economy of industrialized countries increasingly relies
on the service sector. This new reality has transformed the nature
of work injuries and disability. The shift from manufacturing and
resource-based jobs to the service industry led to a sharp reduc-
tion in acute and fatal injuries but contributed to the current
epidemic of musculoskeletal disorders (MSDs).
45
Today MSDs
are the most burdensome ailments that affect the health and
reduce the productivity of workers.
56
Neck pain is one of the most prevalent MSDs in the working-
age population
48
and a leading source of disability and health care
utilization among adults.
18,19
During any 6-month period, 54%of
adults suffer from neck pain and 4.6% experience significant
activity limitations because of neck problems.
18
Contrary to
popular belief, most adults with neck pain do not experience
complete permanent resolution of their discomfort; in fact, it
follows an episodic course marked by periods of remission and
exacerbation.
20
Each year between 14.6% and 18.0% of adults
develop a new episode of neck pain,
20,21,48
which causes a new
episode of disability in 600/100,000 adults annually.
20
The etiology of neck pain in workers is complex and multifac-
torial. Its hypothesized risk factors include demographics, psy-
chosocial and work-related issues, and poor general health.
5,7,16,17,20
Although the etiologic contribution of work receives increasing
attention, most studies remain cross-sectional and can be used only
to hypothesize about the causes of neck pain.
5,7
Understanding
its etiology in workers is necessary to develop, test, and imple-
ment prevention strategies to reduce its burden.
PURPOSE
The purpose of this chapter is to review and appraise the recent lit-
erature on the epidemiology of neck pain in workers. Specifically,
we review the literature to answer the following questions:
1. What is the prevalence of neck pain in workers? We define
prevalence as the proportion of workers with neck pain
during a specific period of time; its measurement is useful to
quantify the burden of a condition in a defined population.
2. What demographic, socioeconomic, health- and work-
related, psychosocial, and societal factors are associated with
prevalent neck pain in workers? We refer to associated fac-
tors to describe variables that are correlated with neck pain
in cross-sectional studies. Although these cannot be used to
draw causal inferences about its etiology, they are useful to
describe the potential risk factors for neck pain.
3. What is the incidence of neck pain in workers? We use the
term incidence to describe the average risk of developing
neck pain during a time period. A measure of incidence is
not only useful to describe the proportion of the workers
who will develop a new episode of neck pain during a
specific time period but also necessary to quantify the
etiologic contribution of risk factors. Incidence is meas-
ured from cohort studies.
4. What are the risk factors for neck pain in workers? Risk factors
are things that may contribute to on help predict neck pain.
We have collected information on risk factorsvariables that
increase or reduce riskfrom case-control and cohort studies.
METHODS
We wrote this chapter in collaboration with the members of the
scientific secretariat of the 2000-2010 Bone and Joint Decade
Task Force on Neck Pain and Its Associated Disorders. The Task
Force includes a multidisciplinary scientific secretariat of 12 clini-
cians and methodologists representing rheumatology, orthopedic
surgery, physical and rehabilitative medicine, neurology, physio-
therapy, health psychology, chiropractic, epidemiology, clinical
epidemiology, and biostatistics. A main objective was to complete
a systematic search and critical review of the scientific literature on
neck pain and its associated disorders. The literature reviewed in
this chapter was critically appraised by members of the Task Force
using a standardized critical appraisal methodology.
Definition of neck pain
We define neck pain as soft tissue disorders of the cervical
spine/shoulder area, including disk lesions and radiculopathy
that are experienced by workers. Our definition does not assume
a causal link between work and neck pain. It includes neck
pain that is caused or aggravated by work, that which interferes
with work, and symptomatic neck pain that does not result in
disability.
Literature search
Having developed our literature search strategy in collaboration
with a library scientist (see Acknowledgments), we applied it to
two electronic databases: MEDLINE and Embase ( January 1997
to October 2003). For the purpose of this chapter, we used a
restricted portion of the exhaustive search undertaken by the
Task Force. Our search was based on specific key words (neck pain,
neck injury, pain, injury, epidemiology, incidence, prevalence,
C HA P T E R
3a
*Eugene J. Carragee, Jaime Guzman, Scott Haldeman, Sheilah Hogg-Johnson, Lena
Holm, Eric Hurwitz, Margareta Nordin, Paul M. Peloso, and Gabrielle van der Velde.
workplace, worker, work, meta-analysis) and text words (neck
pain, cervical pain, neck ache, whiplash, pain, ache, sore, stiff,
discomfort, neck, occupational, work-related, review, literature
synthesis, literature review). All search terms were limited to the
English and French languages and adult subjects. We excluded
duplicate articles.
Article selection
Each citation found in the search was screened by rotating
groups of three Task Force scientific secretariat members to assess
its relevance to the epidemiology of neck pain in workers. For
the purpose of this review, articles were deemed relevant if they
passed the following inclusion and exclusion criteria:
Inclusion criteria
1. Studies that report results relevant to neck pain in workers
with or without its associated disorders, which might include
radiating arm pain, upper thoracic pain, headache, and tem-
poromandibular joint disorder pain;
2. Studies that examine the prevalence, incidence, risk,
and/or prevention of neck pain with or without its associ-
ated disorders;
3. Studies of the risk or prevention of neck pain that include
at least 20 human subjects at risk for neck pain with or
without its associated disorders.
Exclusion criteria
1. Studies that do not include human subjects with neck pain
with or without its associated disorders;
2. Studies of neck pain due to fracture, dislocation, tumor,
skin lesions, throat disorders, inflammatory disorders,
cervical myelopathy, and spinal cord injury;
3. Studies concerning radiating arm pain, upper thoracic
pain, headaches, temporomandibular joint disorder, and
thoracic outlet syndrome not associated with neck pain;
4. Opinion papers, letters to the editor, traditional narrative
reviews, and papers without scientific data;
5. Single-case reports of workers with neck pain with or with-
out its associated disorders;
6. Studies using cadavers or nonhuman subjects, such as crash
test dummies, animals, or laboratory simulations;
7. Biomechanical studies without human subjects with neck
pain.
Critical review of the literature
All articles meeting the inclusion and exclusion criteria were
critically reviewed using standard criteria and computerized crit-
ical review forms. Modified for the purpose of the 2000-2010
Task Force, the forms were similar to the ones used by the
Quebec Task Force on Whiplash-Associated Disorders and the
Best Evidence Synthesis on Traumatic Mild Injury (Appendix
3a.1).
12,55
These criteria prompt the reviewers to appraise the
methodologic merit of a study by focusing on selection bias,
information bias, and confounding. Rather than provide a rating
scale for determining scientific acceptability, the forms are used
to assist reviewers in understanding the impact of bias on the
study results and to abstract information.
Rotating pairs of scientific secretariat members independently
conducted these in-depth reviews of each article, and the remain-
ing members read the studies. The two reviewers presented their
critical appraisal to a larger group of members for discussion of
the scientific merit of the study. The members decided by con-
sensus whether a study was scientifically admissible or inadmis-
sible, the latter being one in which methodologic flaws were
judged to have fatally biased the results and therefore made the
papers conclusions scientifically invalid.
Data synthesis
Each research question was answered by a best-evidence
synthesis,
52,53
which consists of assembling and qualitatively
synthesizing the best evidence relevant to it. We described the
strength of evidence for risk factors by adapting a methodology
that has been used to rank studies on breast cancer, whiplash
injuries, and mild traumatic brain injuries.
4,13,19
The methodol-
ogy distinguishes among three phases of studies. Phase I studies
are hypothesis-generating investigations that descriptively
explore associations between potential risk factors and disease
outcomes. Phase II studies are extensive exploratory analyses
that focus on particular sets of risk factors or attempt to discover
which ones predict the development of neck pain. Phase III stud-
ies are large confirmatory studies of explicit prestated hypotheses
that allow for focused examinations of the strength, direction,
and independence of the proposed relationship between a risk
factor and the development of neck pain.
We present the prevalence and incidence of neck pain with
95% confidence intervals. Where these figures were not reported
in the article but sufficient information was provided, we com-
puted these estimates and report our computations. We describe
the cross-sectional associations between various risk factors and
neck pain as positive or negative. We report odds ratios, relative
risks or hazard rate ratios, and 95% confidence intervals to
describe associations between risk factors and neck pain obtained
from case-control or cohort studies. When these estimates did
not appear in the paper, they were computed from sufficient
data. Confidence intervals for prevalence and incidence rates
were calculated using the standard confidence interval formula
around proportions described by Kuzma.
37
All other analyses
were performed using SAS.
49
RESULTS
Selection and critical appraisal of articles
The results from the literature search and selection of articles are
summarized in Figure 3a.1. Overall, we retrieved 162 publica-
tions, including 152 articles from the literature search and 10
from our files. Of the 159 nonduplicate articles, 45 met the
inclusion criteria and were reviewed. Fifteen articles were
excluded by the scientific secretariat after they were appraised as
scientifically inadmissible.
10,11,15,26,31-34,36,40,41,43,61,63,64
Of the 30 accepted articles, 18 were cross-sectional studies
that reported on the prevalence and factors associated with neck
pain,
1-3,22-25,28-30,39,42,44,46,47,58-60
and 10 reported on its incidence
Chapter 3a Prevalence, incidence, and risk factors of neck pain in workers 26
Chapter 3a Results
and risk factors.
6,8,27,35,38,50,51,54,57,62
Two studies reported cross-
sectional and prospective results.
9,14
Neck pain in general working populations
Prevalence
We accepted four cross-sectional studies that described the
prevalence of neck pain in samples of workers from the general
population, in this case in Europe.
9,14,23,46
The source population
for these studies varied from registers of general practitioners
in the United Kingdom to age cohorts of workers under the
supervision of occupational physicians in France, workers who
participated in periodical health surveys in the Netherlands, and
34-year old workers in Sweden. Overall, these studies suggest
that neck pain is highly prevalent and a common source of
activity limitations.
In the United Kingdom, 34% of workers reported that they
experienced neck pain in the preceding year (Table 3a.1).
46
During the same period, 11% of workers limited their activities
because of neck pain. Overall, 20% of surveyed workers had
experienced neck pain in the preceding week. In Sweden, the
1-year prevalence of neck pain was 44% and 61% in 34-year-old
men and women, respectively (Table 3a.1).
9
In this cohort, 26%
of men and 43% of women reported symptoms that lasted more
than 1 month. In France during 1990, the prevalence of chronic
neck/shoulder pain lasting for at least 6 months and associated
with functional limitations was 7.8% in men and 14.8% in
women (Table 3a.1).
14
In 1995 this same study reported that the
prevalence of chronic neck/shoulder pain had increased slightly
to 9.5% in men and 17.6% in women.
Factors associated with neck pain
All four studies reported that the prevalence of neck pain increases
with age and is more common in women (Table 3a.1).
9,14,23,46
In
Sweden, self-employed males had a higher prevalence of
neck/shoulder symptoms in the past month than other workers.
9
In the United Kingdom, workers with musculoskeletal
comorbidities were more likely to report neck pain. Palmer et al
46
reported that the prevalence of neck pain in the preceding week
was higher in those with shoulder, elbow, wrist-hand, hip, and
knee pain. Similarly, neck pain was more common in workers
who had experienced troublesome low back pain in the preced-
ing year and in those who suffered from frequent headaches,
fatigue, or stress.
9,46
Barnekow-Bergkvist et al
9
found that work-
ers with better flexibility of the cervical spine (rotation) reported
fewer neck/shoulder symptoms in the preceding month.
Three studies reported that ergonomic, physical, and psychoso-
cial factors at work are associated with neck pain (Table 3a.1). Two
studies reported on its association with lifting. In Sweden, the
prevalence of neck symptoms in the preceding month was lower
in workers who performed repetitive or heavy lifting,
9
whereas in
contrast, Palmer et al
46
reported that lifting increased it. Among
U.K. workers, the prevalence of neck pain was found to be higher
also in workers who reached overhead for more than 1 hour per
day and in those exposed to hand and arm vibration.
46
Using
a keyboard for 4 hours or more in an average working day was
positively associated with neck pain in women but not in men.
47
A positive association between monotonous work, high decision
latitude, and prevalent neck/shoulder symptoms was found
among female workers in the Swedish sample.
9
Finally, Dutch
adult workers who reported a combination of mentally and
physically demanding work and those performing heavily
27
Medline
Librarian
Scientific
secretariat
Scientific
secretariat
109 10 43
162 articles
159 non-duplicate articles
45 relevant articles
114 irrelevant
15 rejected
1. Literature search
2. Screening
Inclusion criteria
Critical appraisal
30 articles accepted and reviewed
3. Review
Embase Personal files
Figure 3a.1 Results of literature search and selection of articles included in the review.
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.
Chapter 3a Results 29
demanding work were more likely to report regular pain or stiff-
ness in the neck.
23
Incidence
Three cohort studies, two conducted in France and one in the
United States, provided information about the incidence of neck
pain in samples of workers from the general population. The
studied populations included workers under supervision of
French occupational physicians/medical departments in the early
1990s
14
and those covered by the Washington State Department
of Labor and Industries state fund (including employees of self-
insured employers) between 1990 and 1998.
51
These studies sug-
gested that a significant proportion of the working population
experiences a new episode of neck pain each year.
These cohort studies offered insights about the high-risk
groups for the development of an episode of neck pain. In
France the 6-month incidence of neck pain among workers
with no prior history was 17.4%, whereas it was 44.4% in those
who reported a past history of neck disorders.
38
Between 1990
and 1995, 12.5% female French workers and 7.3% of male French
workers developed chronic neck pain (Table 3a.2).
14
In
Washington State, 40.1 per 10,000 full-time equivalent workers
covered by the state fund developed neck pain.
51
However, the
reported incidence was only 5.1 per 10,000 full-time equivalent
employees in self-insured firms.
Risk factors for neck pain
Four phase II studies reported on factors associated with the
development of neck pain in general working populations. Three
Swedish studies described risk factors for developing neck pain
in the past year, and one French study reported on the risk fac-
tors for chronic neck pain.
In a Swedish cohort of 16-year-old student-workers, bench press
performance was negatively associated with the development of
neck/shoulder pain 18 years later (Table 3a.2).
9
In other words,
workers who performed better while bench pressing when 16 years
of age in 1974 were protected against developing neck/shoulder
pain in 1992. In another study, Fredriksson et al
27
found that the
development of neck/shoulder pain was associated with physical
and psychosocial factors at work, specifically high physical work
load for men and frequent hand movement for women. The
authors found, moreover, that physical and psychosocial risk fac-
tors frequently interact and modify their effects on the incidence
of neck/shoulder pain in workers. A third Swedish study found
that both physical and psychosocial risk factors contribute to
workers seeking health care for neck/shoulder pain.
57
A previous
episode of neck pain that persisted for more than 3 months and
a nonfixed salary strongly predicted seeking health care for this
symptom. The risk factors as well as the strength and the direction
of association varied between men and women, suggesting that
the etiology has a gender-specific component.
57
For men, exposure
to psychosocial factors such as high job demands or high time
pressure reduced the risk of seeking care (Table 3a.2). In women,
however, exposure to other psychosocial risk factors such as high
degree of hindrance with work increased the risk of seeking
care for neck/shoulder pain. Tornqvist et al
57
also reported that
workers with multiple risk factors were more likely to seek care.
In France, the risk of developing chronic neck pain and dis-
ability was associated with sociodemographic variables, workplace
psychosocial factors, comorbidities, and health risk behaviors
(Table 3a.2). In their large cohort, Cassou et al
14
found that
increasing age, repetitive work, and high job demands were asso-
ciated with chronic neck pain. Moreover, workers with depressive
symptoms and those suffering from MSDs in the preceding year
were more likely to develop chronic neck pain.
Neck pain in specific occupational groups
Prevalence
Twelve cross-sectional studies described the prevalence and
factors associated with neck pain in samples of health care
workers, including dental personnel, physical therapists and
nurses,
1-3,22,24,39,58-60
music and nursery school teachers,
25,44
and
blue collar workers (sewage workers, spinning industry, forestry,
and scaffolding).
28-30,42
The available evidence suggests that the
prevalence of neck pain varies across occupations and tends to
be higher for health care workers (Table 3a.3).
Among these workers, the 1-year prevalence of neck pain varies
from 45.8% in nurses to 47.6% in physical therapists, 64% in
dentists, and 72% in dental hygienists (Table 3a.3).
1,2,22,39,58-60
In
Sweden, it is estimated that 50% of dental hygienists experience
neck pain in the preceding week, whereas in Norway, 22.6% of
nursing aides report that they experienced intense neck pain in
the preceding 2 weeks.
2,24
The prevalence of chronic neck pain is
9% among the nursing staff of Greek hospitals.
3
In Sweden, most
music teachers (59%) experience neck pain every year, and 30%
experience an episode each week.
25
Similarly, one fourth to one
third of Japanese nursery school teachers report neck pain each
month.
44
Interestingly, except for sewage workers the prevalence
of neck pain is lower in industrial, forestry, and construction
workers than in health care workers or teachers. In Austrian
sewage workers, the annual prevalence of neck pain is 52.4%, and
20.9% of workers suffer from neck pain each day.
28
Factors associated with neck pain
In health care workers, the presence of neck pain was associated
with demographic, ergonomic, and workplace factors. Among
nurses, neck pain was more common in older workers and in those
with moderate/high physical or psychologic demands.
39,58-60
Nurses
and nursing aides who worked long hours reported neck pain
more frequently.
24,39,58-60
Although neck pain was more common
in those who worked under strenuous back postures, it was less
so in those who used mechanical lifts or received ergonomic
training.
3,24,39,58-60
In physical therapists, neck pain was positively
associated with the pace of work and the type of practice.
22
The association between neck pain and physical/psychologic
variables was observed also in Japanese nursery school teachers,
among whom it was more common in those with poor supervi-
sor support and in those caring for young children.
44
Similarly,
male Swedish music teachers with low social support and women
teachers with high psychologic demands were more likely to
report neck pain.
25
Neck pain in blue collar workers was associ-
ated with age, physical work, and psychologic demands.
28,30
Incidence of neck pain
Five cohort studies describe the incidence of neck pain in specific
occupational groups, including industrial/service companies,
6,8
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i
n
s
u
r
e
d
s
o
f
t

t
i
s
s
u
e

d
i
s
o
r
d
e
r
s

S
t
a
t
e

f
u
n
d
:

4
0
.
1

(
3
9
.
6
,
4
0
.
6
)
o
f

L
a
b
o
r

a
n
d

c
l
a
i
m
s
,
o
n
l
y

t
h
o
s
e

w
i
t
h

m
o
r
e

t
h
a
n

w
i
t
h

t
h
e

n
e
c
k

a
s

t
h
e

S
e
l
f
-
i
n
s
u
r
e
d

e
m
p
l
o
y
e
r
s
:

I
n
d
u
s
t
r
i
e
s

S
t
a
t
e

3

d
a
y
s

o
f

l
o
s
t

t
i
m
e

w
e
r
e

i
n
c
l
u
d
e
d
.
p
r
i
m
a
r
y

s
i
t
e

o
f

i
n
j
u
r
y
5
.
1

(
4
.
9
,
5
.
3
)
F
u
n
d

a
n
d

S
a
m
p
l
e

s
i
z
e

=
3
9
2
,
9
2
5
e
m
p
l
o
y
e
e
s

o
f

s
e
l
f
-
i
n
s
u
r
e
d

e
m
p
l
o
y
e
r
s

b
e
t
w
e
e
n

1
9
9
0

a
n
d

1
9
9
8
T
o
r
n
q
v
i
s
t

e
t

a
l
,
W
o
r
k
e
r
s

i
n

t
h
e

I
n
c
l
u
s
i
o
n
:

w
o
r
k
e
r
s

a
g
e
d

2
0
-
5
9

y
e
a
r
s
C
a
s
e
s

w
e
r
e

t
h
o
s
e

w
h
o

N
o
t

a
p
p
l
i
c
a
b
l
e
M
e
n
:
2
0
0
1
5
7
m
u
n
i
c
i
p
a
l
i
t
y

o
f

w
h
o

w
o
r
k
e
d

m
o
r
e

t
h
a
n

1
7

h
o
u
r
s
/
s
o
u
g
h
t

t
r
e
a
t
m
e
n
t

f
o
r

S
u
f
f
e
r
e
d

f
r
o
m

n
e
c
k

o
r

s
h
o
u
l
d
e
r

s
y
m
p
t
o
m
s

>
3

m
o
n
t
h
s
C
a
s
e
-
c
o
n
t
r
o
l

N
o
r
r
t
l
j
e
,
w
e
e
k

a
n
d

h
a
d

w
o
r
k
e
d

a
t

l
e
a
s
t

n
e
c
k
-
s
h
o
u
l
d
e
r

d
i
s
o
r
d
e
r
s
e
a
r
l
i
e
r

i
n

l
i
f
e
:

R
R

=
4
.
4

(
2
.
7
-
7
.
1
)
;

w
o
r
k

w
i
t
h

v
i
b
r
a
t
i
n
g

s
t
u
d
y
S
w
e
d
e
n

f
r
o
m

2

m
o
n
t
h
s

d
u
r
i
n
g

t
h
e

p
a
s
t

y
e
a
r
C
o
n
t
r
o
l
s

w
e
r
e

r
a
n
d
o
m
l
y

t
o
o
l
s
:

R
R

=
1
.
6

(
1
.
0
-
2
.
3
)
;

n
o
n
f
i
x
e
d

s
a
l
a
r
y

R
R

=
1
.
9

P
h
a
s
e

I
I
S
e
p
t

1
,
1
9
9
4

t
o

E
x
c
l
u
s
i
o
n
:

s
e
e
k
i
n
g

h
e
a
l
t
h

c
a
r
e

f
r
o
m

t
h
e

p
o
p
u
l
a
t
i
o
n

r
e
g
i
s
t
e
r
(
1
.
1
-
3
.
1
)
;

h
i
g
h

d
e
m
a
n
d
s

R
R

=
0
.
7

(
0
.
4
-
1
.
0
)
;

h
i
g
h

t
i
m
e

J
u
n
e

3
0
,
1
9
9
7
f
o
r

n
e
c
k
,
s
h
o
u
l
d
e
r
,
o
r

l
o
w

b
a
c
k

C
o
n
t
r
o
l

g
r
o
u
p

=
1
5
1
1
p
r
e
s
s
u
r
e

R
R

=
0
.
5

(
0
.
3
-
1
.
0
)
;

h
i
g
h

c
r
e
a
t
i
v
i
t
y
/
l
o
w

r
o
u
t
i
n
e

d
i
s
o
r
d
e
r
s

d
u
r
i
n
g

t
h
e

6

m
o
n
t
h
s

w
o
r
k

p
r
o
f
i
l
e

R
R

=
0
.
6

(
0
.
4
-
1
.
0
)
;

h
i
g
h

q
u
a
n
t
i
t
a
t
i
v
e

d
e
m
a
n
d
s
b
e
f
o
r
e

e
n
r
o
l
l
m
e
n
t
R
R

=
0
.
2

(
0
.
1
-
0
.
9
)
;

l
o
w

d
e
m
a
n
d
s

i
n

r
e
l
a
t
i
o
n

t
o

S
a
m
p
l
e

s
i
z
e

=
1
9
0
3
c
o
m
p
e
t
e
n
c
e

R
R

=
1
.
5

(
1
.
0
-
2
.
4
)
W
o
m
e
n
:
S
u
f
f
e
r
e
d

f
r
o
m

n
e
c
k

o
r

s
h
o
u
l
d
e
r

s
y
m
p
t
o
m
s

>
3

m
o
n
t
h
s

e
a
r
l
i
e
r

i
n

l
i
f
e
:

R
R

=
4
.
1

(
3
.
0
-
5
.
7
)
;

r
e
p
e
t
i
t
i
v
e

h
a
n
d
/
f
i
n
g
e
r

m
o
v
e
m
e
n
t
s

R
R

=
1
.
6

(
1
.
2
-
2
.
2
)
;

n
o
n
f
i
x
e
d

s
a
l
a
r
y

R
R

=
2
.
0

(
1
.
0
-
4
.
2
)
;

n
i
g
h
t
s
h
i
f
t
/
s
h
i
f
t

w
o
r
k

i
n
c
l
u
d
i
n
g

n
i
g
h
t

w
o
r
k

R
R

=
1
.
3

(
1
.
0
-
1
.
8
)
;

l
o
n
g

w
o
r
k
i
n
g

h
o
u
r
s

R
R

=
0
.
7

(
0
.
5
-
0
.
9
)
;

s
o
l
i
t
a
r
y

w
o
r
k

R
R

=
1
.
8

(
1
.
2
-
2
.
9
)
;

j
o
b

s
t
r
a
i
n

R
R

=
1
.
4

(
1
.
1
-
2
.
0
)
;

h
i
g
h

d
e
g
r
e
e

o
f

h
i
n
d
r
a
n
c
e
s

a
t

w
o
r
k

R
R

=
1
.
4

(
1
.
0
-
1
.
9
)
C
I
,
c
o
n
f
i
d
e
n
c
e

i
n
t
e
r
v
a
l
;

M
S
D
,
m
u
s
c
u
l
o
s
k
e
l
e
t
a
l

d
i
s
o
r
d
e
r
;

O
R
,
o
d
d
s

r
a
t
i
o
n
;

R
R
,
r
e
l
a
t
i
v
e

r
i
s
k
.
T
a
b
l
e

3
a
.
3
S
t
u
d
i
e
s

o
f

p
r
e
v
a
l
e
n
c
e

a
n
d

f
a
c
t
o
r
s

a
s
s
o
c
i
a
t
e
d

w
i
t
h

n
e
c
k

p
a
i
n

i
n

s
p
e
c
i
f
i
c

o
c
c
u
p
a
t
i
o
n
s
I
n
c
l
u
s
i
o
n
/
e
x
c
l
u
s
i
o
n
S
t
u
d
y
S
o
u
r
c
e

p
o
p
u
l
a
t
i
o
n
c
r
i
t
e
r
i
a
C
a
s
e

d
e
f
i
n
i
t
i
o
n
s
P
r
e
v
a
l
e
n
c
e

(
9
5
%

C
I
)
A
s
s
o
c
i
a
t
e
d

f
a
c
t
o
r
s

(
9
5
%

C
I
)
A
k
e
s
s
o
n

e
t

a
l
,
D
e
n
t
a
l

p
e
r
s
o
n
n
e
l

(
d
e
n
t
i
s
t
s
,
E
x
c
l
u
s
i
o
n
:

p
e
r
s
o
n
n
e
l

N
e
c
k

p
a
i
n

m
e
a
s
u
r
e
d

1
-
w
e
e
k

p
r
e
v
a
l
e
n
c
e
:
N
o
t

a
p
p
l
i
c
a
b
l
e
1
9
9
9
1
d
e
n
t
a
l

h
y
g
i
e
n
i
s
t
s
,
a
n
d

o
n

l
e
a
v
e

(
o
t
h
e
r

t
h
a
n

w
i
t
h

t
h
e

S
t
a
n
d
a
r
d
i
z
e
d

H
y
g
i
e
n
i
s
t
s
:

5
0
%

(
3
3
,
6
7
)
;

m
a
l
e

d
e
n
t
i
s
t
s
:

3
1
%

A
k
e
s
s
o
n

e
t

a
l
,
d
e
n
t
a
l

a
s
s
i
s
t
a
n
t
s
)

f
r
o
m

s
i
c
k

l
e
a
v
e
)

a
n
d

N
o
r
d
i
c

Q
u
e
s
t
i
o
n
n
a
i
r
e
(
1
6
,
4
5
)
;

f
e
m
a
l
e

d
e
n
t
i
s
t
s
:

2
7
%

(
1
2
,
4
2
)
;

2
0
0
0
2
t
h
e

p
u
b
l
i
c

h
e
a
l
t
h

s
p
e
c
i
a
l
i
s
t

d
e
n
t
i
s
t
s
g
e
n
e
r
a
l

p
r
a
c
t
i
c
e

d
e
n
t
a
l

a
s
s
i
s
t
a
n
t
s
:

1
7
%

(
1
0
,
2
4
)
;
s
e
r
v
i
c
e
s

i
n

t
h
e

c
o
u
n
t
y

S
a
m
p
l
e

s
i
z
e

=
2
4
4
s
p
e
c
i
a
l
i
s
t

d
e
n
t
a
l

a
s
s
i
s
t
a
n
t
s
:

1
6
%

(
4
,
2
7
)
o
f

B
l
e
k
i
n
g
e
,
S
w
e
d
e
n
1
-
y
e
a
r

p
r
e
v
a
l
e
n
c
e
:
H
y
g
i
e
n
i
s
t
s
:

7
2
%

(
5
6
,
8
7
)
;

m
a
l
e

d
e
n
t
i
s
t
s
:

6
4
%

(
4
9
,
7
9
)
;

f
e
m
a
l
e

d
e
n
t
i
s
t
s
:

6
4
%

(
4
7
,
8
0
)
;

g
e
n
e
r
a
l

p
r
a
c
t
i
c
e

d
e
n
t
a
l

a
s
s
i
s
t
a
n
t
s
:

4
6
%

(
3
7
,
5
5
)
;
s
p
e
c
i
a
l
i
s
t

d
e
n
t
a
l

a
s
s
i
s
t
a
n
t
s
:

3
4
%

(
1
9
,
4
9
)
P
r
e
v
a
l
e
n
c
e

a
t

5
-
y
e
a
r

f
o
l
l
o
w
-
u
p

f
o
r

f
e
m
a
l
e
s
.
1
-
w
e
e
k

p
r
e
v
a
l
e
n
c
e
:
H
y
g
i
e
n
i
s
t
s
:

4
1
%
;

d
e
n
t
i
s
t
s
:

3
8
%
;

d
e
n
t
a
l

a
s
s
i
s
t
a
n
t
s

3
1
%
1
-
y
e
a
r

p
r
e
v
a
l
e
n
c
e
:
H
y
g
i
e
n
i
s
t
s
:

7
3
%
;

d
e
n
t
i
s
t
s
:

5
4
%
;

d
e
n
t
a
l

a
s
s
i
s
t
a
n
t
s

6
2
%
A
l
e
x
o
p
o
u
l
o
s

N
u
r
s
i
n
g

s
t
a
f
f

f
r
o
m

s
i
x

I
n
c
l
u
s
i
o
n
:

a
t

l
e
a
s
t

o
n
e

N
e
c
k

p
a
i
n

m
e
a
s
u
r
e
d
1
-
y
e
a
r

p
r
e
v
a
l
e
n
c
e
:

4
7
%

(
4
2
-
5
2
)
S
t
r
e
n
u
o
u
s

b
a
c
k

p
o
s
t
u
r
e

(
+
)
;

m
o
d
e
r
a
t
e
/
b
a
d

e
t

a
l
,
2
0
0
3
3
h
o
s
p
i
t
a
l
s

i
n

A
t
h
e
n
s
,
y
e
a
r

o
f

e
x
p
e
r
i
e
n
c
e

i
n

w
i
t
h

t
h
e

S
t
a
n
d
a
r
d
i
z
e
d
P
r
e
v
a
l
e
n
c
e

o
f

c
h
r
o
n
i
c

n
e
c
k

p
a
i
n
:

9
%

(
6
-
1
2
)
p
e
r
c
e
i
v
e
d

g
e
n
e
r
a
l

h
e
a
l
t
h

(
+
)
G
r
e
e
c
e

b
e
t
w
e
e
n

2
0
0
0

c
u
r
r
e
n
t

j
o
b
N
o
r
d
i
c

Q
u
e
s
t
i
o
n
n
a
i
r
e
P
r
e
v
a
l
e
n
c
e

o
f

s
i
c
k

l
e
a
v
e
:

5
%

(
3
-
7
)
a
n
d

2
0
0
1
S
a
m
p
l
e

s
i
z
e

=
3
5
1
C
h
r
o
n
i
c

n
e
c
k

p
a
i
n

i
s

p
a
i
n

l
a
s
t
i
n
g

>
3

m
o
n
t
h
s
C
r
o
m
i
e

e
t

a
l
,
P
h
y
s
i
c
a
l

t
h
e
r
a
p
i
s
t
s

E
x
c
l
u
s
i
o
n
:

t
h
e
r
a
p
i
s
t
s

N
e
c
k

p
a
i
n

m
e
a
s
u
r
e
d

1
-
y
e
a
r

p
r
e
v
a
l
e
n
c
e
:

4
7
.
6
%

(
4
3
.
3
-
5
1
.
8
)
M
a
l
e

(
+
)
,
p
r
i
v
a
t
e

p
r
a
c
t
i
c
e

(
+
)
,
s
p
o
r
t
s

2
0
0
0
2
2
r
e
g
i
s
t
e
r
e
d

i
n

t
h
e

s
t
a
t
e

n
o
t

l
i
v
i
n
g

i
n

A
u
s
t
r
a
l
i
a
w
i
t
h

t
h
e

S
t
a
n
d
a
r
d
i
z
e
d
p
h
y
s
i
c
a
l

t
h
e
r
a
p
y

(
+
)
,
m
a
n
u
a
l

t
e
c
h
n
i
q
u
e
s

(
+
)
,
o
f

V
i
c
t
o
r
i
a
,
A
u
s
t
r
a
l
i
a
S
a
m
p
l
e

s
i
z
e

=
5
3
6
N
o
r
d
i
c

Q
u
e
s
t
i
o
n
n
a
i
r
e
s
e
d
e
n
t
a
r
y

w
o
r
k

(
+
)
,
r
e
p
e
t
i
t
i
v
e

t
a
s
k
s

(
+
)
,
l
a
r
g
e

n
u
m
b
e
r

o
f

p
a
t
i
e
n
t
s
/
d
a
y

(
+
)
,
f
e
w

r
e
s
t

p
e
r
i
o
d
s

(
+
)
,
r
e
s
t

p
e
r
i
o
d
s

(
+
)
,
w
o
r
k

w
h
e
n

i
n
j
u
r
e
d

(
+
)
,
m
o
b
i
l
i
z
a
t
i
o
n
/
m
a
n
i
p
u
l
a
t
i
o
n

(
+
)
,
o
t
h
e
r

m
a
n
u
a
l

t
r
e
a
t
m
e
n
t

(
+
)
E
r
i
k
s
e
n
,
N
o
r
w
e
g
i
a
n

n
u
r
s
e
s

I
n
c
l
u
s
i
o
n
:

v
o
c
a
t
i
o
n
a
l
l
y

a
c
t
i
v
e
N
e
c
k

p
a
i
n

m
e
a
s
u
r
e
d

2
-
w
e
e
k

p
r
e
v
a
l
e
n
c
e
:
F
e
m
a
l
e

(
+
)
,
m
a
r
i
t
a
l

s
t
a
t
u
s
/
s
i
n
g
l
e

(
+
)
,
2
0
0
3
2
4
a
i
d
e
s

i
n

1
9
9
9
E
x
c
l
u
s
i
o
n
:

s
i
c
k

l
e
a
v
e

b
e
c
a
u
s
e
w
i
t
h

t
h
e

S
t
a
n
d
a
r
d
i
z
e
d

A
n
y

p
a
i
n
:

5
3
.
5

%

(
5
2
.
3
-
5
4
.
7
)
w
o
r
k
i
n
g

>
3
6

h
o
u
r
s
/
w
e
e
k

(
+
)
,
w
o
r
k
i
n
g

i
n

o
l
d
o
f

i
l
l
n
e
s
s

o
r

p
r
e
g
n
a
n
c
y
N
o
r
d
i
c

Q
u
e
s
t
i
o
n
n
a
i
r
e
I
n
t
e
n
s
e

p
a
i
n
:

2
2
.
6
%

(
2
1
.
6
-
2
3
.
6
)
p
e
o
p
l
e
s

h
o
m
e

(
+
)
S
a
m
p
l
e

s
i
z
e

=
6
4
8
5
F
j
e
l
l
m
a
n
-
M
u
s
i
c

t
e
a
c
h
e
r
s

i
n

t
w
o

I
n
c
l
u
s
i
o
n
:

a
l
l

m
u
s
i
c

t
e
a
c
h
e
r
s
N
e
c
k

p
a
i
n

m
e
a
s
u
r
e
d

1
-
y
e
a
r

p
r
e
v
a
l
e
n
c
e
:
M
e
n
:
W
i
k
l
u
n
d

c
o
u
n
t
i
e
s

o
f

S
w
e
d
e
n

i
n
S
a
m
p
l
e

s
i
z
e

=
2
0
8
w
i
t
h

t
h
e

S
t
a
n
d
a
r
d
i
z
e
d

C
u
m
u
l
a
t
i
v
e
:

5
9
%

(
5
2
-
6
6
)
L
o
w

s
o
c
i
a
l

s
u
p
p
o
r
t

(
+
)
;

l
i
f
t
i
n
g

(
+
)
;

e
t

a
l
,
2
0
0
3
2
5
2
0
0
0
N
o
r
d
i
c

Q
u
e
s
t
i
o
n
n
a
i
r
e
M
e
n
:

5
2
%

(
4
3
-
6
1
)
p
l
a
y
i
n
g

g
u
i
t
a
r

(
+
)
W
o
m
e
n
:

6
7
%

(
5
7
-
7
7
)
W
o
m
e
n
:
1
-
w
e
e
k

p
r
e
v
a
l
e
n
c
e
:
H
i
g
h

p
s
y
c
h
o
l
o
g
i
c

d
e
m
a
n
d
s

(
+
)
;

t
e
a
c
h
i
n
g

C
u
m
u
l
a
t
i
v
e
:

3
0
%

(
2
4
-
3
6
)
a
t

5
-
1
2

s
c
h
o
o
l
s
/
w
e
e
k

(
+
)
M
e
n
:

2
6
%

(
1
8
-
3
4
)
W
o
m
e
n
:

3
6
%

(
2
6
-
4
6
)
F
r
i
e
d
r
i
c
h

S
e
w
a
g
e

w
o
r
k
e
r
s

f
r
o
m

I
n
c
l
u
s
i
o
n
:

j
o
b

i
n
v
o
l
v
i
n
g

N
e
c
k

p
a
i
n

m
e
a
s
u
r
e
d

L
i
f
e
t
i
m
e

p
r
e
v
a
l
e
n
c
e
:

6
7
.
5
%

(
6
1
.
6
-
7
3
.
3
)
A
g
e

(
+
)
e
t

a
l
,
2
0
0
0
2
8
V
i
e
n
n
a
,
A
u
s
t
r
i
a
h
e
a
v
y

l
i
f
t
i
n
g

o
r

w
o
r
k
i
n
g

w
i
t
h

t
h
e

S
t
a
n
d
a
r
d
i
z
e
d

1
-
y
e
a
r

p
r
e
v
a
l
e
n
c
e
:

5
2
.
4
%

(
4
6
.
0
-
5
8
.
5
)
w
h
i
l
e

b
e
n
t

o
v
e
r
N
o
r
d
i
c

Q
u
e
s
t
i
o
n
n
a
i
r
e
1
-
w
e
e
k

p
r
e
v
a
l
e
n
c
e
:

2
5
.
7
%

(
2
0
.
3
-
3
1
.
3
)
S
a
m
p
l
e

s
i
z
e

=
2
5
5
P
o
i
n
t

p
r
e
v
a
l
e
n
c
e
:

2
0
.
9

(
1
5
.
8
-
2
6
.
0
)
G
a
m
p
e
r
i
e
n
e

W
o
r
k
e
r
s

f
r
o
m

t
h
e

I
n
c
l
u
s
i
o
n
:

p
r
o
d
u
c
t
i
o
n

N
e
c
k

p
a
i
n

m
e
a
s
u
r
e
d

1
-
y
e
a
r

p
r
e
v
a
l
e
n
c
e
:

1
6
.
5
%

(
1
2
.
4
,
2
0
.
8
)
N
o
t

a
p
p
l
i
c
a
b
l
e
a
n
d

S
t
i
g
u
m
,
s
p
i
n
n
i
n
g

i
n
d
u
s
t
r
y

i
n

w
o
r
k
e
r
s
w
i
t
h

t
h
e

S
t
a
n
d
a
r
d
i
z
e
d

1
9
9
9
2
9
L
i
t
h
u
a
n
i
a

i
n

1
9
9
6
S
a
m
p
l
e

s
i
z
e

=
3
6
3
N
o
r
d
i
c

Q
u
e
s
t
i
o
n
n
a
i
r
e
H
a
g
e
n

e
t

a
l
,
F
o
r
e
s
t
r
y

w
o
r
k
e
r
s

I
n
c
l
u
s
i
o
n
:

m
a
n
u
a
l

w
o
r
k
e
r
s
,
N
e
c
k
/
s
h
o
u
l
d
e
r

p
a
i
n

f
o
r
1
-
y
e
a
r

p
r
e
v
a
l
e
n
c
e
:

2
7
.
7
%

(
2
1
.
9
,
3
3
.
5
)
A
g
e

(
+
)
;

p
h
y
s
i
c
a
l

w
o
r
k

(
+
)
;

l
o
w

i
n
t
e
l
l
e
c
t
u
a
l

1
9
9
8
3
0
f
r
o
m

N
o
r
w
a
y
m
a
c
h
i
n
e

o
p
e
r
a
t
o
r
s
,
a
n
d

a
t

l
e
a
s
t

3
0

d
a
y
s

i
n

d
i
s
c
r
e
t
i
o
n

(
+
)
;

h
i
g
h

p
s
y
c
h
o
l
o
g
i
c

d
e
m
a
n
d
s

(
+
)
a
d
m
i
n
i
s
t
r
a
t
i
v
e

w
o
r
k
e
r
s

p
r
e
v
i
o
u
s

1

y
e
a
r

w
h
o

w
o
r
k
e
d

f
o
r

a
t

l
e
a
s
t

m
e
a
s
u
r
e
d

w
i
t
h

t
h
e

1
0

m
o
n
t
h
s
/
y
e
a
r

d
u
r
i
n
g

S
t
a
n
d
a
r
d
i
z
e
d

N
o
r
d
i
c

t
h
e

p
r
e
v
i
o
u
s

5

y
e
a
r
s
Q
u
e
s
t
i
o
n
n
a
i
r
e
S
a
m
p
l
e

s
i
z
e

=
8
3
5
M
o
l
a
n
o

W
o
r
k
e
r
s

f
r
o
m

a

s
c
a
f
f
o
l
d
i
n
g
I
n
c
l
u
s
i
o
n
:

a
l
l

w
o
r
k
e
r
s
N
e
c
k

p
a
i
n

m
e
a
s
u
r
e
d

1
-
y
e
a
r

p
r
e
v
a
l
e
n
c
e
:

2
7
%

(
2
2
,
3
2
)
N
o
t

a
p
p
l
i
c
a
b
l
e
e
t

a
l
,
2
0
0
1
4
2
c
o
m
p
a
n
y

i
n

t
h
e

S
a
m
p
l
e

s
i
z
e

=
3
2
3
w
i
t
h

t
h
e

S
t
a
n
d
a
r
d
i
z
e
d

N
e
t
h
e
r
l
a
n
d
s

f
r
o
m

J
u
n
e

N
o
r
d
i
c

Q
u
e
s
t
i
o
n
n
a
i
r
e
t
o

S
e
p
t
e
m
b
e
r
,
1
9
9
8
O
n
o

e
t

a
l
,
N
u
r
s
e
r
y

s
c
h
o
o
l

t
e
a
c
h
e
r
s
E
x
c
l
u
s
i
o
n
:

m
a
l
e

w
o
r
k
e
r
s
,
N
e
c
k
/
s
h
o
u
l
d
e
r

p
a
i
n

i
n

N
o
t

a
p
p
l
i
c
a
b
l
e
1
0

y
e
a
r
s

o
f

e
x
p
e
r
i
e
n
c
e

(
+
)
;

c
a
r
i
n
g

f
o
r

c
h
i
l
d
r
e
n

2
0
0
2
4
4
i
n

a

J
a
p
a
n
e
s
e

c
i
t
y
,
n
u
r
s
e
s
,
s
u
p
e
r
v
i
s
o
r
s
t
h
e

p
r
e
v
i
o
u
s

m
o
n
t
h

a
g
e
d

0

(
+
)
;

h
o
l
d
i
n
g
/
l
i
f
t
i
n
g

a

c
h
i
l
d
/
m
a
t
e
r
i
a
l

i
n

O
c
t
o
b
e
r
,
1
9
9
5
S
a
m
p
l
e

s
i
z
e

=
9
5
9
g
r
e
a
t
e
r

t
h
a
n

g
r
a
d
e

3
/
5

e
x
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Chapter 3a Relevance 35
municipal office workers,
35
teaching hospital employees,
50
female
nurses from acute care hospitals,
54
and workers from a large
forestry industry.
62
Overall, the evidence suggests that the inci-
dence of neck pain varies across occupational group, tending to
be higher for those working in hospitals and offices (Table 3a.4).
In England, female nurses working in acute care hospital set-
tings developed neck pain at a rate of 17% per year.
54
In Canada,
40.5% of employees at a teaching hospital who were asympto-
matic in 1996 reported to have experienced an episode of neck
pain in the preceding week when followed up a year later.
50
In
Finnish municipal office workers, the annual incidence of neck
pain with or without radiations was 34.4%. Approximately 13%
had local neck pain only, and 14.4% had radiating pain without
neck pain. The annual incidence of workers reporting both local
and radiating neck pain was 6.7%.
35
The incidence of neck pain was lower among workers in
industrial/service and forestry sectors. In workers from 34 indus-
trial/service companies located throughout the Netherlands, the
3-year incidence of neck pain was 14.4%.
6,8
The overall 3-year
incidence among Finnish forestry workers was a similar 15.6%
62
:
9.2% developed mild neck pain, and 6.4% developed severe pain.
Risk factors for neck pain
Two phase II and one phase I study examined the risk factors
for neck pain in specific occupational groups (Table 3a.4).
Among Finnish municipal workers, females and those with
poor keyboard position were more likely to develop neck pain.
35
In English female nurses, a new episode of neck pain was associ-
ated with previous neck and low back pain and with various
physical aspects of care such as moving and transferring
patients.
54
Only one phase III study supported the observation that
physical and psychosocial factors contribute to the development
of neck pain.
5,8
In their cohort study of industrial and service
workers from the Netherlands, Ariens et al
5,8
demonstrated that
high quantitative job demands, low coworker support, and pro-
longed sitting are independent risk factors for a new episode of
neck pain.
SUMMARY
Neck pain is endemic in workers. Our best evidence synthesis
demonstrates that it is highly prevalent and a common source of
disability. By far, most neck pain in workers is nontraumatic. Its
etiology is consequently multifaceted, and although occupa-
tional factors may be important contributors to its development,
they are neither sufficient nor necessary. This reality clearly
emphasizes that the development of an episode of neck pain
cannot be attributed entirely to the physical and psychosocial
environment of a workplace.
Our review of cross-sectional studies supports the view that neck
pain is more common in various subgroups of workers. It is more
prevalent among older workers, women, and those with muscu-
loskeletal comorbidities.
1,2,14,23,24,28,30,39,46,54,57-60
Moreover, it varies
significantly across occupations and is associated with ergonomic,
physical, and psychosocial factors.
3,5,8,9,14,22,23,25,27,30,35,39,44,46,54,57-60
Evidence from case-control and cohort studies confirms that cer-
tain occupations pose higher risk of developing an episode of
neck pain; specifically, we found its incidence to be higher for
nurses and office workers.
35,50,51
Studies that quantified the role
of risk factors supported that neck pain is more common in
workers with high quantitative job demands, low coworker sup-
port, repetitive work, nonfixed salary, increased sitting time,
poor ergonomics, previous musculoskeletal pain, and depressive
symptoms.
5,8,14,27,35,54,57
Although we identified several risk factors for neck pain, it is
important to note that only one phase III study was designed
specifically to test their independence.
5,8
This finding indicates
that very few risk factors can be considered well established.
Efforts should be devoted to designing phase III studies to
confirm the results of cross-sectional observations and phase II
(exploratory) studies. Moreover, future studies should pay
attention to interactions among individual, psychosocial, and
workplace risk factors. The growing body of evidence supporting
the role of psychosocial and workplace factors in the etiology
of neck pain must not be considered in isolation. Because it is
very likely that the risk factors for the development of neck pain
and disability vary across occupations, as demonstrated in our
review, future studies should ensure that the risk profiles of vari-
ous occupations are explored.
RELEVANCE
Our review has important implications for prevention. First,
intervention must target clearly modifiable risk factors. Second,
the multifaceted etiology of neck pain highlights the importance
of designing preventive interventions focused on multiple rather
than individual risk factors. Current research has not yet identi-
fied the necessary causes for neck pain and disability, and very
little is known about the interrelationships among risk factors.
Multimodal interventions targeting multiple modifiable risks
such as workplace and psychosocial factors may thus prove more
promising than one-dimensional approaches targeting a specific
one. Finally, the complex etiology of neck pain suggests that
the roles of economic and legal factors, work organization, and
health care access and delivery are important and must be
studied as well.
14
ACKNOWLEDGMENTS
We are indebted to Emma Irvin and Stephen Greenhalgh, research librar-
ians, for their expertise and guidance with the literature search.
The Bone and Joint Decade Task Force on Neck Pain and Its Associated
Disorders is supported by a grant to the University of Alberta from the
National Chiropractic Mutual Insurance Company and the Canadian
Chiropractic Protective Association, Jalan Pacific Inc., Lnsfrskringar
Wasa, and the Insurance Bureau of Canada. This article was made possi-
ble also through the financial support of the Workplace Safety and
Insurance Board of Ontario. Dr. Ct is supported by the Canadian
Institutes of Health Research through a New Investigator Award and by
the Institute for Work & Health by the Workplace Safety and Insurance
Board of Ontario. Dr. Carroll is supported by a Health Scholar Award
from the Alberta Heritage Foundation for Medical Research. Dr. Cassidy
is supported by an endowed research chair from the University Health
Network. Vicki Kristman is supported by a Doctoral Training Award from
the Canadian Institutes of Health Research in partnership with the
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3
Chapter 3a Relevance 37
S
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Canadian Institute for the Relief of Pain and Disability (formally known
as the Physical Medicine Research Foundation) Woodbridge Grants and
Awards Program and by the Institute for Work & Health by the Workplace
Safety and Insurance Board of Ontario.
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Chapter 3a References 39
Appendix 3a.1
GENERAL METHODOLOGIC ISSUES
USED FOR ALL STUDY DESIGN
1. Research question is clearly stated
2. Source and target population identified and described
3. Inclusion criteria described and appropriate
4. Exclusion criteria described and appropriate
5. Number of excluded or refusals (before study) reported
6. Withdrawals (during study) reported, explained, and
reasonable
7. Withdrawals equal in groups
8. Statistical analyses appropriate
9. Adjustment for important variables measured at entry
into study
10. Results verifiable from raw data
CRITERIA FOR THE APPRAISAL
OF THE METHODOLOGIC QUALITY
OF CROSS-SECTIONAL STUDIES
1. Similar sampling procedures for all subjects
2. Similar ascertainment of exposure for all subjects
3. Similar referral and diagnostic procedures for all subjects
4. Diagnostic criteria for disease (clear, reliable, and valid)
5. Characteristics of subjects at enrollment reported
6. All aspects of exposure measured (level, dose, duration, etc.)
7. Coexposures measured
8. Recall bias controlled
9. Data collection valid and reliable
10. Selection bias considered
11. Analyses controls for confounding factor
OF COHORT STUDIES
1. Zero time identified
2. Baseline comparability reported (including confounding
variables)
3. Same data collection for all cohorts
4. Important baseline variables measured, valid, and reliable
5. All aspects of exposure measured (dose, level, duration)
6. Exposure adequately measured (previous, at entry, during
study)
7. Regular follow-up periods
8. Coexposures monitored
9. Duration of follow-up adequate
10. Outcome(s) defined and measurable
11. Outcome(s) valid
12. Blind assessment of outcome(s)
13. Analyses controls for confounding
OF CASE-CONTROL STUDIES
1. Similar population sources for cases and controls (time,
place, potential for exposure)
2. Referral and sampling independent of exposure
3. Random selection of controls
4. Diagnostic criteria for cases clear, precise, and valid
5. Date of diagnosis for case operationally defined
6. Ascertainment of disease adequate for cases and controls
7. Comparison of cases and controls at enrollment reported
(including confounding variables)
8. All aspects of exposure measured (level, dose, duration, etc.)
9. Exposure adequately measured (same in all groups,
blinded)
10. Coexposures measured
11. Recall bias controlled
12. Data collection valid and reliable
13. Analysis according to level of exposure
14. Effect of matching assessed
C HA P T E R
3b
Biomechanics of the
Cervical and Thoracic Spine
Jiri Dvorak and Malcolm Pope
BIOMECHANICS OF THE NECK
The biomechanics of the cervical spine is determined by the shape
of the vertebral bodies and the orientation of the zygapophyseal
joints and can accordingly be divided into three sections:
Upper cervical spine: occiput, atlas, axis;
Lower cervical spine: C2-C3 to C7;
Cervical-thoracic junction: C7 to the third thoracic vertebra

(Fig. 3b.1).
The primary aim of the clinician treating a patient with neck
pain is to find the region or even segment responsible for pain
symptoms. Because the intersegmental nerve root anastomosis
makes it almost impossible for a patient suffering from neck
pain to localize the exact origin of pain,
11,12,26
the clinician must
base the diagnosis on functional and palpatory examinations
of the cervical spine. To do this correctly requires analysis and
interpretation of normal and disturbed motion patterns based
on a knowledge of clinical biomechanics and an understanding
of developmental anatomy.
The natural aging process results in many changes in the
cervical spine that must be taken into account in the clinical
assessment, especially as related to range of motion. It is well
established that range of motion decreases with age, mainly in
the middle and lower segments of the cervical spine.
4
This is due
to the ongoing transformation process of the intervertebral disk
and the development of uncovertebral joints
14,29
; later it may
also be due to development of osteoarthritis of the zygapophy-
seal joints.
In the first two decades of life, the uncovertebral spaces of
the lower part of the cervical spine begin to undergo a lifelong
transformation into uncovertebral joints. This transformation is
a response to the compressive force of the weight of the head,
which the upright posture of the body requires the cervical spine
to support (Fig. 3b.2).
14,28,29
The result is the formation of lateral
tears of the disk annulus beginning in the second decade of
life (Fig. 3b.3). These lateral tears continue to develop into the
medial center part of the disk until, in the third decade, com-
plete transverse tears commonly occur (Fig. 3b.4).
28
The resulting
space in the middle of the intervertebral disk partially takes over
the function of the zygapophyseal joints during the second and
third decades. (At this stage, the nucleus pulposus dries out,
appearing on radiographs as a narrowing between the vertebrae
of the lower cervical spine, which provides a convenient way for
the clinician to monitor these changes.)
This new space within the disk significantly reduces the load-
absorbing function of the intervertebral disk in the cervical spine.
To support the load of the head, a transformation of the
uncovertebral joints starts to occur.
28
Instead of the original
pointed shape, the uncovertebral processes now become flat
Upper cervical spine
Lower
cervical spine
Cervical-thoracic
junction
C2
C3
C4
C5
C6
C7
Th1
Th2
Th3
Figure 3b.1 Sections of the cervical spine.
Figure 3b.2 Drawing of the uncovertebral joints. (From Luschka H:
Die Halbgelenke des menschlichen Krpers. Berlin, 1858, Reimers.)
with a shape like that of a cow horn (Fig. 3b.5) and take over
the load of the cranial vertebrae. The overall result is a natural
transformation of the structure and shape of the uncovertebral
processes that is probably responsible for much of the decreased
range of motion that accompanies aging and must be taken into
account in any clinical assessment of the cervical spine.
In the first two decades of life, the surfaces of the articular
processes are covered by a thin layer of cartilage, with the uneven
surfaces filled in by a synovial fold in the joint capsule. This
synovial fold has been described by Penning and Tndury
21
as
meniscoid. It is found within the entire cervical spine (Fig. 3b.6)
and again degenerates or atrophies with increasing age.
UPPER CERVICAL SPINE: OCCIPUT/C2
The upper cervical spine, which consists of the occiput, atlas, and
axis, is responsible for most of the axial rotation and some of the
flexion-extension and lateral bending of the head. In addition
to allowing large rotations, it must be stable enough to support
the weight of the head and protect the delicate spinal cord
and intervertebral arteries from injury and is therefore quite a
complicated structure. Possible motion in the atlantooccipital
and atlantoaxial joints is determined by the orientation of the
articular processes. The occipital condyles are an oval-shaped
bean-like form with a sagittal orientation of the joint axis of
28 degrees on average (Fig. 3b.7).
8,10
The frontal orientation
of the joint axis (Fig. 3b.8) averages 124 degrees in males and
127 degrees in females.
9,27
The motion axis of the atlantooccipital joints was described
by Knese
9
(Fig. 3b.9). The atlantooccipital joints are described
as a spheroid articulation. They are connected with a tight joint
capsule that limits the movements possible. The dominant
movement in the atlantooccipital joint is flexion and extension
of approximately 22 to 24 degrees, according to the author.
Lateral bending, again according to the author, is between 5 and
10 degrees. The idea of axial rotation in this joint has long
been rejected; however, newer investigations by Dvorak et al
7
showed axial rotation in both in vitro and in vivo studies.
A summary of movements possible in the atlantooccipital joint
is shown in Table 3b.1.
The atlantoaxial joint consists of four joint spaces: the two
atlantoaxial lateral joints, the atlantoaxial median joint (between
the anterior arch of the atlas and the dens axis), and a joint
between the posterior surface of the dens and the transverse
ligament, which is connected to the anterior joint space. From
the medial part arises a large synovial fold in the lateral atlantoax-
ial joint (Fig. 3b.10).
4
This joint capsule is loose, which allows for
a great deal of motion. It is here that most of the axial rotation
occurs. The movements possible in the atlantoaxial joints are
summarized in Table 3b.2.
Motion within the upper cervical spine, especially in the
atlantoaxial joint, is mainly limited by ligaments that, with
exception of the tectorial membrane, consist of nonstretchable
collagen fibers.
24,25
The tectorial membrane, which consists of
elastic fibers, inserts at the great occipital foramen and distally
joins the posterior longitudinal ligament. The biomechanical
properties of the tectorial membrane have been studied by
Oda et al,
17
who documented their large elasticity.
Chapter 3b Biomechanics of the cervical and thoracic spine 42
Figure 3b.4 Frontal section of the cervical spine of a 33-year-old
man. In the three lowest segments, each intervertebral disk shows
a complete transverse tear; however, the upper two levels have only
lateral tears. (From Tndury G, Theiler K: Entwicklungsgeschichte
und Fehlbildungen der Wirbelsule, ed 2, Stuttgart, Germany, 1990,
Hippokrates-Verlag.)
Figure 3b.3 Frontal section of the cervical spine of a 9-year-old child.
Remnants of cartilage are still present. The arrow points to a space in
the lateral part of the intervertebral disk at level C3-C4.
Chapter 3b Upper cervical spine: occiput/C2 43
A B
C D
E F
Figure 3b.5 Cow horn-like shapes (arrows). Changes
of the uncovertebral disks at the C4-C5 and C5-C6
levels of the same subject at the age of 47 years (A)
and 49 years (B). At the same level on the lateral
views, anterior and posterior osteophytes are starting
to form (C and D) and narrow the intervertebral
foramen at the C5-C6 level (E and F).
Figure 3b.6 Parasagittal section of the intervertebral joints
(zygapophyseal joints) at the level of C4 and C6. The articular
processes show an inclination of approximately 45 degrees. The arrow
points to the synovial folds in between the intervertebral joint surfaces,
which have been described by Penning and Tndury as meniscoid.
(Courtesy Professor Doctor W. Rauschning, Uppsala, Sweden.)
Figure 3b.7 Sagittal orientation of the occipital condyles is 28 degrees
on average. (From Ingelmark BE: Acta Anat (Basel) 6:1-48, 1947.)
124
Frontal orientation of joint axis
Figure 3b.8 Frontal orientation of the occipital condyles according to
Stoff. (From Stoff E: Verh Anat Gesch Jena 70:575, 1976.)
Y-axis
Z-axis
X-axis
Figure 3b.9 Possible joint axis of the upper cervical spine according
to Knese. (From Knese KH: Z Anat Entwickl 114:67-107, 1949.)
Table 3b.1 Possible movements in the
atlantooccipital joint according to different authors
Flexion/extension
Occipto-C1 (total) rotation Side bending
joint (one side) (one side) Axial
Fick (1904) 50 30-40 0
Poirer and Charpy
(1926) 50 14-40 0
Werne (1957)
30
13 8 0
Penning (1978)
20
35 10 0
Dvorak et al (1985) 5.2
Clark et al (1986) 22.7 4.8
Dvorak et al (1987)
3
4
Penning and Wilmink
(1987)
22
1
Panjabi et al (1988)
19
24.5 5.5 7.2
The cruciate ligament (Fig. 3b.11) has the important function
of restricting potentially dangerous anterior gliding of the
atlas during flexion movement of the head while still allowing
the atlas to turn freely around the dens during axial rotation.
It consists of two main parts: a horizontally oriented transverse
ligament and vertically oriented longitudinal fibers. The trans-
verse ligament inserts at the medial portion of the lateral mass
of the atlas. The caudal fibers are occasionally fixed at the base
of the dens and may additionally stabilize the dens (Fig. 3b.12).
At the level of the dens is a thin layer of cartilage covering
the transverse ligament,
5
which allows the ligament to move
more freely and protects it from damage caused by friction.
The transverse ligament consists exclusively of collagen fibers
with an interesting fiber orientation similar to a folding lattice
(Fig. 3b.13). This allows extensive stretching of the ligament
during axial rotation without damage to the fibers. In vitro exper-
iments show failure of the transverse ligament to occur between
170 and 700 N.
5
The main limiting structures for the upper cervical spine are
the alar ligaments. Consisting exclusively of nonstretchable
collagen fibers, the alar ligaments connect the dens axis with the
occipital condyles and the anterior arch of the atlas (Fig. 3b.12).
1,3,13
Occasionally, a loose connection is also found between the basis
of the dens axis and the anterior arch of the atlas
3
; this has been
described by Von Barrow as the atlantodental anterior ligament.
According to Werne,
30
alar ligaments are of great importance
in limiting axial rotation (Fig. 3b.14), a belief that has been
confirmed by newer investigations.
5,18
In conjunction with the
tectorial membrane, the alar ligaments also limit flexion of the
occiput. During lateral bending (Fig. 3b.15), the alar ligament
is responsible for forced rotation of the second vertebra.
5,30
The apical ligament has no functional meaning and is actually a
rudiment of the chorda dorsalis.
10
Clinical analysis of upper cervical spine motion can be done
through the use of functional radiographs. In the anteroposterior
view, lateral bending can be assessed.
23
Physiologic movements,
gliding of the atlas in bending direction, and forced rotation of the
axis are presented in Figure 3b.16 as seen on functional radio-
graphs. Axial rotation is currently assessed through measurements
of functional computed tomography and may in the future be
tested by functional magnetic resonance imaging (Fig. 3b.17).
2,6
Chapter 3b Upper cervical spine: occiput/C2 45
Table 3b.2 Summary of possible motions at the
atlantoaxial joint according to various authors
Flexion/ Axial
extension Side bending rotation
C1-C2 joint (total) (one side) (one side)
Fick (1904) 0 0 60
Poirer and Charpy
(1926) 11 30-80
Werne (1957)
30
10 0 47
Penning (1978)
20
30 10 70
Dvorak et al (1985) 32.2
Clark et al (1986) 10 14.5
Dvorak et al (1987)
3
43.1
Penning and Wilmink
(1987)
22
40.5
Panjabi et al (1988)
19
22.4 6.7 38.9
A B
Figure 3b.10 Dissection of normal left atlantoaxial meniscoid from a fresh cadaveric specimen (A); the surface is covered with meniscoid (B).
LOWER CERVICAL SPINE
The anatomic structures of the motion segments of the lower
cervical spine are different from those in the upper cervical
spine. Their particularities include the uncovertebral joints,
which support part of the axial load once the intervertebral disk
loses its elasticity due to age-related transformations.
14,28,29
The
articular processes of the cervical spine are inclined approxi-
mately 45 degrees from the horizontal plane (Fig. 3b.18), with
steeper inclinations in the lower segments. The transverse processes
hide and protect the spinal nerve and vertebral artery.
The motion segments are connected and stabilized by liga-
ments, anteriorly by the anterior longitudinal ligament (Fig. 3b.19)
and dorsally by the posterior longitudinal ligament. The density
of nociceptive and mechanoreceptive innervation of the poste-
rior longitudinal ligament is high in comparison with other
cervical spine ligaments and the disk.
16
This results in a very sen-
sitive ligament that indirectly controls the innervation of neck
muscles through nociceptive and mechanoreceptive reflexes.
32
The laminae are connected by the strong ligamentum flavum,
which consists almost exclusively of elastic fibers and is a major
limiting structure in flexion movement.
The dominant motion in the lower cervical spine is flexion-
extension. Different parameters can be measured with flexion-
extension x-ray views, including segmental rotation, translatory
movement, and the location of the center of rotation (Fig. 3b.20).
7
Because a significant motion difference exists between actively
and passively performed movements, the use of passively per-
formed radiographs has been recommended in diagnosing
segmental instability, such as can occur after trauma (Fig. 3b.21).
6,7
The first description of the center of rotation in healthy adults
came from Penning and Tndurys measurements
21
of flexion
and extension radiographs. The center of rotation has been
determined with computer-assisted methods
7
and has confirmed
Penning and Tndurys findings (Fig. 3b.22). Table 3b.3 shows
the relevant data on flexion-extension movements of healthy
adults for in vitro and in vivo examinations. Table 3b.4 presents
data on rotation, translation, and center of rotation as measured
by computer-assisted methods on a healthy population.
7
Lysell
15
described the so-called top angle, or segmental arch, as
being flat at the level of C2 and steep at the lower cervical spine.
Motion of the upper segments during flexion-extension is there-
fore fairly horizontal, whereas motion of the lower segments is
more like that of an arc (Fig. 3b.23).
Atlantoaxial
articulation
Transverse ligament
Posterior longitudinal
ligament
Tectorial membrane
Transverse occipital ligament
Alar ligament
Cruciate ligament
Dura
Clivus
Jugular foramen
Hypoglossal canal
Atlantooccipital
articulation
Figure 3b.11 Ligaments of the upper cervical spine, posterior view. (From Lang J: Klinische Anatomie der Halswirbelsule. New York, 1991,
Georg Thieme Verlag.)
Anterior atlantodental ligament
Alar ligament
(atlantal portion)
Alar ligament
(occipital portion)
Transverse
ligament
Figure 3b.12 Drawing of the ligaments of the upper cervical
spine (axial dissection). (From Dvorak J, Froehlich D, Penning L,
Baumgartner H, Panjabi MM: Spine 13(7):748-755, 1988.)
Chapter 3b Lower cervical spine 47
Figure 3b.13 The orientation of the collagen fibers of the transverse ligament is similar to a folding lattice and allows extensive stretching of the
ligament during flexion and axial rotation without damage to the fibers.
Figure 3b.14 Drawing of possible movements in the atlantoaxial joint during axial rotation of the head according to Werne. (From Werne S: Acta
Orthop Scand Suppl 23:80, 1957.)
Left lateral bending Right lateral bending
C
2
C
0
C
1
x +x
y y
y
y
1 y
1
z
+y
+y
+z
Figure 3b.15 Function of the alar ligaments during
side bending of the head. (From Dvorak J, Froehlich D,
Penning L, Baumgartner H, Panjabi MM: Spine
13(7):748-755, 1988.)
Figure 3b.16 Forced rotation of the axis and gliding
of the atlas in the direction of bending as seen from
functional radiographs in the anteroposterior view.
(From Reich C, Dvorak J: Manual Med 2, 1986.)
Figure 3b.17 Functional computed tomography of the upper
cervical spine during axial rotation within the atlantoaxial and
atlantooccipital joints.
Figure 3b.17 Contd
Figure 3b.18 Orientation of the articular processes of the lower cervical spine in the frontal plane. (From White AA, Panjabi MM: Clinical
biomechanics of the spine, ed 2. Philadelphia, 1990, JB Lippincott.)
G. Facets
E. Intertransverse ligament
A. Anterior
longitudinal ligament
B. Anterior one-half
annulus fibrosus
C. Posterior one-half
annulus fibrosus
D. Posterior longitudinal ligament
F. Capsular
ligament
I. Interspinous and
superspinous
ligaments
H. Ligamentum
flavum
A
B
C
D
D
E
F
G
H
I
Figure 3b.19 Ligaments of the anterior and posterior parts
at the lower cervical spine. (From White AA, Panjabi MM:
Clinical biomechanics of the spine, ed 2. Philadelphia, 1990,
JB Lippincott.)
+Y
+Z
+X
X
+RX
+RY
+RZ
Z
Y
RX
BZ
BY
AY
CRY
CRZ
AZ
Figure 3b.20 Parameters for measurement of segmental motion using computer-assisted methods. RX is the rotation about the x-axis; CRY and
CRZ are the centers of rotation of the Y and Z rotations, respectively; AY, AZ, BY, and BZ are the translations of point A in the Y and Z directions
and point B in the Y and Z directions, respectively.
D
C
A B
Figure 3b.21 Female, aged 51, 1 year after injury to the cervical spine. The examination has been performed during active and passive motion
(A-D) and measured according to Pennings method (E and F).
C1/C2 C2/C3 C3/C4 C4/C5
Hypermobile
C5/C6 C6/C7
35
30
20
25
15
5
0
10
Passive
Average + 2 STDV
Average + 1 STDV
Average
Average 1 STDV
Average 2 STDV
Z.A., F, 51y
E
C1/C2a C2/C3a C3/C4a C4/C5a
Hypomobile
C5/C6a C6/C7a
35
30
20
25
15
5
0
10
Active
Average + 2 STDV
Average + 1 STDV
Average
Average 1 STDV
Average 2 STDV
Z.A., F, 51y
F
Active
Active
Passive
Hypermobile
Passive
Z.A., f, 51Y
G
Figure 3b.21 Contd According to the functional
diagram, there is a significant difference in segmental
motion, especially as related to segments C3-C4 and
C6-C7. Drawing the vertebral bodies on a transparent
paper (G) makes the difference obvious. (From Dvorak J,
Froehlich D, Penning L, Baumgartner H, Panjabi MM:
Spine 13(7):748-755, 1988.)
Table 3b.3 Summary of flexion-extension movements of healthy adults in vivo and in vitro
Dvorak (1988) Dvorak (1988) Penning (1978)
20
Flexion/Extension (Total) (In Vivo/Passive) (In Vivo/Active) White and Panjabi (1978)
31
(In Vivo/Active)
C2-C3 10.0 12.0 8.0 12.0
C3-C4 15.0 17.0 13.0 18.0
C4-C5 19.0 21.0 12.0 20.0
C5-C6 20.0 23.0 17.0 20.0
C6-C7 19.0 21.0 16.0 15.0
Table 3b.4 Averages and standard deviations of
rotations, translations, and coordinates of center of
rotation as measured by computer-assisted methods
Parameter* C1-C2 C2-C3 C3-C4 C4-C5 C5-C6 C6-C7
RX (deg) 15.4 11.7 16.0 20.1 21.5 21.0
Male 6.1 3.1 2.5 2.8 3.9 4.0
RX (deg) 12.9 12.3 18.3 22.1 24.1 21.8
Female 3.4 3.0 4.7 3.9 4.0 3.5
AZ (mm) 3.8 2.4 3.2 3.6 2.9 2.0
1.6 0.9 1.0 1.2 1.1 0.9
AY (mm) 6.2 1.8 2.3 2.9 3.2 3.1
2.3 0.8 1.0 0.7 0.8 0.8
BZ (mm) 1.4 6.9 8.5 10.0 9.8 8.4
1.4 1.7 1.8 1.9 1.9 1.9
BY (mm) 8.1 3.0 3.6 4.2 4.3 3.9
3.0 1.3 1.2 1.0 1.0 0.9
CRZ (mm) 4.1 4.0 4.3 6.0 6.4 6.4
4.2 3.5 2.7 2.2 1.8 2.5
CRY (mm) 30.0 9.4 9.7 10.4 12.9 17.2
5.6 4.8 3.4 2.8 2.5 2.1
*See Figure 3b.20 for definitions.
Penning Dvorak
Figure 3b.22 Determination of the center of rotation by graphic method
(Penning, 1960) and by using computer-assisted methods on a normal
population. (From Dvorak J, Schneider E, Saldinger P, Rahn B: J Orthop
Res 9:828-834, 1991.)
Neutral Left bending Right bending
Figure 3b.24 Coupled axial rotation during lateral bending of the
head. (From White AA, Panjabi MM: Clinical biomechanics of the spine,
ed 2. Philadelphia, 1990, JB Lippincott.)
C7
C4
C2
Figure 3b.23 Segmental arch of the top angle according to Lysell.
9
The flatter the articular surfaces, the flatter the top angle of the motion
segments and vice versa.
Lateral bending of the cervical spine is normally coupled
with axial rotation to the same side.
15,31
This means that the
spinal processes are moving in a direction opposite the motion
(Fig. 3b.24). This coupled motion is of clinical importance
because palpation of the spinal processes can serve as an indirect
indicator of disturbed function in motion segments. The lateral
bending of the cervical spine below the first cervical vertebra has
been variously reported by different researchers. According to
Penning,
20
the lateral bending is 35 degrees, whereas White and
Panjabi
31
reported between 4 and 10 degrees per motion segment.
Axial rotation, as measured with functional computed tomogra-
phy, is between 3 and 7 degrees,
2,22
but an in vitro study
19
showed a higher result, between 8 and 12 degrees. Tables 3b.5a
and 3b.5b summarize the segmental motions for lateral bending
with coupled axial rotation according to various authors.
REFERENCES
1. Cave AJE: On the occipito-atlanto-axial articulations. J Anat (Lond) 68:416, 1934.
2. Dvorak J, Hayek J, Zehnder R: CT-functional diagnostics of the rotatory instability
of upper cervical spine. Part 2. An evaluation on healthy adults and patients with
suspected instability. Spine 12:726-731, 1987.
3. Dvorak J, Panjabi MM: Functional anatomy of the alar ligaments. Spine 12:183-189,
1987.
4. Dvorak J, Antinnes JA, Panjabi M, Loustalot D, Bonomo M: Age and gender-related
normal motion of the cervical spine. Spine 17(105):5393, 1992.
5. Dvorak J, Schneider E, Saldinger P, Rahn B: Biomechanics of the craniocervical region:
the alar and transverse ligaments. J Orthop Res 6:452-461, 1988.
6. Dvorak J, Froehlich D, Penning L, Baumgartner H, Panjabi MM: Functional radiographic
diagnosis of the cervical spine: flexion/extension. Spine 13(7):748-755, 1988.
7. Dvorak J, Panjabi MM, Novotny JE, Antinnes JA: In vivo flexion/extension of the
normal cervical spine. J Orthop Res 9:828-834, 1991.
8. Ingelmark BE: eber den cranicervicalen bergang beim Menschen. Acta Anat
(Basel) 6:1-48, 1947.
9. Knese KH: Kopfgelenk, Kopfhaltung und Kopfbewegung des Menschen. Z Anat
Entwickl 114:67-107, 1949.
10. Lang J: Craniocervical region, osteology and articulations. Neuroorthopedics
1:67-92, 1986.
11. Lang J: Klinische Anatomie der Halswirbelsule. New York, 1991, Georg Thieme
Verlag.
12. Lang J, Bartram CT: Ueber die Fila articularia der Radices ventrales et dorsales des
menschlichen Rckenmarkes. Gegenbaurs Morphol 128:417-462, 1982.
13. Ludwig K: eber das Lig. alare dentis. Z Anat Entwickl Gesch 116:442, 1952.
14. Luschka H: Die Halbgelenke des menschlichen Krpers. Berlin, 1858, Reimers.
15. Lysell E: Motion in the cervical spine. An experimental study on autopsy specimens.
Acta Orthop Scand Suppl 123:1-61, 1969.
16. Mendel T, Wink CS, Zimny ML: Neural elements in human cervical intervertebral
discs. Spine 17(2):132-135, 1992.
17. Oda T, Panjabi MM, Crisco JJ, Bueff HU, Grob D, Dvorak J: Role of tectorial membrane
in the stability of the upper cervical spine. Clin Biomech 7(4):201-207, 1992.
18. Panjabi M, Dvorak J, Crisco JJ, Oda T, Wang P, Grob D: Effects of alar ligament
transection on upper cervical spine rotation. J Orthop Res 9:584-593, 1991.
19. Panjabi MM, Dvorak J, Duranceau J, Yamamoto I, Gerber M, Rauschning W, Beuff HU:
Three-dimensional movements of the upper cervical spine. Spine 13(7):726-730,
1988.
20. Penning L: Normal movement of the cervical spine. AJR Am J Roentgenol 130:
317-326, 1978.
21. Penning L, Tndury G: Entstehung, Bau und Funktion der meniskoiden Strukturen in
den Halswirbelgelenken. Z Orthop 98:1-14, 1964.
22. Penning L, Wilmink JT: Rotation of the cervical spine: a CT study in normal subjects.
Spine 12:732-738, 1987.
23. Reich C, Dvorak J: The functional evaluation of craniocervical ligaments in sidebending
using x-rays. Manual Med 2, 1986.
24. Saldinger PF: Histologische Untersuchung des kraniozervikalen Bandapparates im
Hinblick auf Weichteilverletzungen der Halswirbelsule. Diss. med., Bern, 1987
(Leitung J. Dvorak).
25. Saldinger PF, Dvorak J, Rahn BA, Perren SM: Histology of the alar and transverse
ligaments. Spine 15:257-261, 1990.
26. Simmons E, Marzo J, Kallen F: Intradural connections between adjacent cervical
spinal roots. Spine 12(10):964-968, 1987.
27. Stoff E: Zur Morphometrie des oberen Kopfgelenks. Verh Anat Gesch Jena 70:575, 1976.
28. Tndury G, Theiler K: Entwicklungsgeschichte und Fehlbildungen der Wirbelsule,
ed 1. Stuttgart, Germany, 1958, Hippokrates-Verlag.
29. Tndury G, Theiler K: Entwicklungsgeschichte und Fehlbildungen der Wirbelsule,
ed 2. Stuttgart, Germany, 1990, Hippokrates-Verlag.
30. Werne S: Studies in spontaneous atlas dislocation. Acta Orthop Scand Suppl 23:80,
1957.
31. White AA, Panjabi MM: The basic kinematics of the human spine. Spine 3:12-20, 1978.
32. Wyke B: Neurological mechanisms in the experience of pain. Acupunct Electrother
Res 4:27-35, 1979.
Table 3b.5b Values of coupled axial rotation
according to various authors
Penning
Coupled axial (1978)
20
White and
rotation Dvorak (1987)
3
(in vivo/ Panjabi
(one side) (in vivo/passive) active) (1978)
31
C2-C3 3.0 3.0 9.0
C3-C4 6.5 6.5 11.0
C4-C5 6.7 6.8 12.0
C5-C6 7.0 6.9 10.0
C6-C7 5.4 5.4 9.0
Table 3b.5a Values of main lateral bending
according to various authors
Main side Moroney White and
bending (1988) Penning (1978)
20
Panjabi
(one side) (in vitro FSU) (in vivo/active) (1978)
31
C2-C3 4.7 6.0 10.0
C3-C4 4.7 6.0 11.0
C4-C5 4.7 6.0 11.0
C5-C6 4.7 6.0 8.0
C6-C7 4.7 6.0 7.0
FSU, functional spinal unit.
C HA P T E R
3c
Evaluation of the Neck
Ronald Moskovich and Anthony Petrizzo
Neck, or cervical spine, pain with concomitant disability is a
common presentation among injured workers. Neck pain, how-
ever, is less prevalent than low back pain as a cause of worker
absenteeism and represents less than 2% of all workplace injuries.
The 1-year prevalence rate of nonwork-related neck pain in most
industrialized countries is approximately 20%; the prevalence of
neck pain during a 1-month period in the United Kingdom is
reported to be 14%.
21
In a cohort of patients with neck pain,
almost half had persistent neck pain 1 year later.
10
Overall, back pain is commonly cited as the second leading
cause of absenteeism in workers and the primary cause of
workers compensation claims. In the Saskatchewan working
age population, 10% experience severe neck pain, with up to
5% having neck pain that severely affects their activities of daily
living.
4
Most of these injuries are diagnosed as either a strain
or sprain. For these types of milder neck injuries, analogous to
the lower spine, it is a challenge to determine the precise
pathoanatomic diagnosis before the initiation of therapy.
STANDARD EXAMINATION
Evaluation of the cervical spine requires a history, using standard
interviewing principles; a physical examination, focused on
elimination of the pertinent negatives; and utilization of
functional assessment scales to measure the impact of cervical
dysfunction on common daily activities. This crucial assessment
of the history with specific questions is used to rule out or deter-
mine the need for an urgent workup, a static and/or dynamic
physical examination, laboratory studies, and further diagnostic
and prognostic evaluations. Although the approach to a patient
injured at work should not differ from that of a patient who
injured his or her neck during recreational activity, patients referred
for work-related cervical spine injury have another aspect added
to their evaluation and assessment: critical return of the patient
to pre- or near preinjury function to resume prior income-related
activities as soon as possible.
DISABILITY EXAMINATION
The critical distinction between a standard medical examina-
tion and a disability examination or impairment evaluation,
lies not only in obtaining the information, but what to do once
pertinent information is obtained (Table 3c.1).
5
For example,
once it is determined that a patient fell at work and is diag-
nosed and treated for the neck injury, the patient must be
further evaluated for his or her ability to attend work and func-
tion in the workplace, albeit with possible job modifications.
This is referred to as a disability evaluation or examination.
A more comprehensive overview of a disability evaluation is
described below.
5
IMPAIRMENT EVALUATION
An impairment evaluation is another type of assessment tool
regarding injury in the workplace. The distinctive contribution
of an impairment evaluation is the measure of functional loss
or derangement of any body part, organ, or organ system.
Another purpose of an impairment evaluation is to measure,
define, and determine the status of the patients (claimants)
general health at a particular point in time. Establishing impair-
ment can be accomplished using different objective methods,
based on guidelines set by the American Medical Association.
3
A diagnosis-related estimate is an impairment method based on
eight diagnosis-related categories (i.e., muscle atrophy, guarding,
asymmetric motion) for each of the three spinal regions. A second
approach in the diagnosis-related estimate method is the diagno-
sis of a fracture or dislocation of the spine that, after appropriate
tests and treatment has been rendered, requires no further ver-
ification. Impairment can also be documented based on assess-
ment of the patients range of motion (ROM). This method is
based on loss of active range of motion (AROM) in addition
to an accompanying diagnosis and a spinal nerve deficit. The
AROM approach is usually reserved for instances when a diagnosis-
related estimate is not applicable.
3
Interestingly, the ability to
participate in work activity is not included in calculating impair-
ment percentages.
The impairment evaluation is performed after the patient is
determined to have achieved the highest possible level of recov-
ery but before they return to work-related activity. Any deviation
from predetermined normal criteria or from the patients prior
health status is translated into an impairment rating. Impairment
can then be converted to impairment percentages, which reflect
the degree to which the impairment decreases the individuals
ability to perform activities of daily living. The development of
an impairment rating is based on clinical decision making,
whereas its purpose usually is to determine financial remuneration
to the claimant by a third party.
5
Table 3c.1 Goals of a disability examination
5
1. Establish a diagnosis
2. Quantify impairment
3. Determine if examinee is capable of performing specified tasks
4. Determine if examinee can attend work
5. Determine if examinee can work in the occupational environment
6. Determine if worker poses a threat to others in the workplace
7. Make a recommendation regarding job modifications
8. Extrapolate into the future
a. Recommend treatment(s)
b. Derive a time course
c. Specify how treatment(s)/time will change points 1 through 7
EVIDENCE-BASED MEDICINE
In recent years, there has been a shift by research and evaluative
bodies to apply evidence-based medicine (EBM) techniques
and outcomes as a foundation for clinical decision making.
11
The U.S. Agency for Health Care Policy and Research (AHCPR),
which convenes expert multidisciplinary nonfederal panels to
develop clinical practice guidelines for specific conditions and
treatments, has similarly embraced the EBM perspective:
Comprehensive evaluation of the results from randomized con-
trol studies is the best available scientific evidence on which to
base clinical decision making. The working goal of the AHCPRs
musculoskeletal panel is to determine a model for the clinical
utility of various diagnostic and therapeutic interventions for
low back pain.
5
This model for evaluating low back pain, although not inter-
changeable for cervical issues, has sound principles that can be
effectively applied to treat cervical spine disorders. The AHCPR
promotes a change in the former paradigm for treating acute
low back pain, from focusing care exclusively on the pain itself
to improving patients activity tolerance once all red flags for
critical disorders have been eliminated.
1
It is our suggestion that
the low back pain model, although not a blueprint for manage-
ment, can be applied to effectively treat cervical disorders as well.
The fact that this approach could be advantageous for both
clinician and patient, at minimum, underscores the importance
and necessity of excluding red flags through the history and
physical examination. The fact that the patient would now be
more focused on movement behavior, and perhaps earlier than
with prior treatment paradigms, underscores an added relevance
to work-related injury cases.
An interest in consistent and well-substantiated assessment
and treatment paradigms are not limited to clinical medicine set-
tings. A landmark U.S. Supreme Court ruling, in 1993, amended
the Federal Rules of Evidence to require experts giving medical
depositions to have reliable data to substantiate their testimony.
2
Since that ruling, concepts supporting and policies enforcing
EBM have expanded through input from epidemiology, outcomes
research, policy makers, and clinicians. To adopt an evidence-
based approach for the care of patients with neck problems, it is
important that practicing clinicians understand the process
of critically evaluating the accuracy of individual studies in the
literature, know the natural history of cervical spine disorders,
and be able to use that knowledge and their clinical experience
as a check-and-balance to their practice decisions.
HISTORY
Interview
A description of the injury and of the precipitating events
provides indispensable information for the treating physician.
The inciting incident can be acute in onset or chronic with a
progressing debility. Documentation must include how and
when the precipitating event occurred as well as its duration.
The history should begin with the identification and essential
demographics of the patient: age, sex, race, and occupation.
The chief complaint(s) should be recorded, at least initially, in
the patients own words. History of the present illness should
include the location, duration, and concise description of symp-
toms and the timing, setting, any aggravating or relieving factors,
and associated manifestations and prior treatments, to include
their effects. It is important to establish whether or not there is a
relationship between the injury and symptoms and the patients
work activities and/or work setting. This part of the history may
require close attention to draw subtle but meaningful informa-
tion from the patient, in part because their pain or discomfort
can make this information difficult to convey or because they
may not be aware of the relationship. From this type of detailed
dialogue with the patient, a statement of the probability that the
injury is work-related is developed.
The primary cause of many injuries can be obvious, whereas
causes or etiologies of the injuries require deeper evaluation.
Patients commonly present with neck complaints after a vehicu-
lar injury, a fall, or rough sport contact. Workers who perform
overhead activities or who carry loads that could strain the neck
muscles may also develop debilitating neck or arm pain. The
symptoms of cervical disease can radiate cephalad to the skull
or caudal to the extremities, where repetitive light to moderate
work activity may be poorly tolerated and reveal underlying
existing pathologies. The presence of a radicular component to
the patients pathology necessitates documentation of the nature
and sources of each of the symptoms.
The patients prior medical history and a review of systems
provide an account of his or her general state of health. A thorough
musculoskeletal history should be done to establish the presence
or absence of overall joint pain, stiffness, swelling, arthritis, gout,
and low back pain. All illnesses and surgeries should be recorded.
A history of gastrointestinal diseases, specifically gastritis and
ulcerative disorders, should be taken, because patients with
cervical ailments may require treatment with nonsteroidal anti-
inflammatory drugs. Specific hereditary predisposing conditions
for inflammatory arthropathies, such as rheumatoid arthritis,
psoriatic arthritis, and ankylosis spondylitis, may be discovered
in the review of family history. Details of tobacco smoking should
also be incorporated into the history. Positive associations
between current smoking and nonspecific back pain were found
in 18 of 26 studies in men and 18 of 20 studies in women.
3
Any history of accidents, at work or home, or occupational expo-
sures must be explored, because they can reveal risky habits or
hazardous conditions. Relevant workers compensation issues
should begin to emerge through the history, but their presence
or impact may continue to be revealed during care of the
patient.
A comprehensive psychosocial history is a valuable but often
overlooked part of the evaluation. Nonphysical or psychosocial
factors such as job or life satisfaction can affect disability status
and treatment outcome. Key features of this review include
the patients life-style, home situation, and vocational and recre-
ational activities. Notably, a history of mental illness, in particu-
lar depression and anxiety, must be addressed. Patients may be
reticent to disclose such information, so its importance and
practical function for treatment and recovery should be carefully
and objectively expressed to the patient and, if necessary, sensi-
tively probed. Finally, a list of the patients current medications,
including prescription, herbal, holistic, over-the-counter, and
borrowed must be reviewed.
Chapter 3c Evaluation of the neck 56
Red flags
After inquiring about the presenting complaint, it is appropriate
to focus on red flags, the presence of which command urgent
evaluation. These red flags include a history of trauma, tumor, or
infection, among others. Patients should be questioned regard-
ing changes in any bowel and bladder habits, specifically an
inability to fully empty the bladder, a feeling of fullness after
urinating, and any history of bladder or bowel incontinence.
Again, these may be difficult questions for patients, and they
should understand that even quite minimal changes in these
behaviors may be important to follow-up if they occur with any
frequency or intermittency. Even though a neurologic examina-
tion will be done, it is important to question the patient about
noticing any loss of manual dexterity as well as the development
of headaches. Patients should be specifically questioned regard-
ing recent fever, weight loss, night sweats, and nocturnal pain.
Table 3c.2 identifies some of the more common red flags.
PHYSICAL EXAMINATION
Inspection
The physical examination typically begins with a general visual
inspection of the patients health and conditioning. It is impor-
tant to inspect the skin for general and isolated color changes.
Warmth and redness are common physical findings with acute
musculoskeletal strain. Posture is examined for asymmetry in
positions such as lateral bending or rotation and the presence of
abnormal sagittal and coronal curves. Ambulation should be
observed for an ataxic broad-based gait, commonly seen in
myelopathy, and any inability to heel-walk or toe-walk, seen with
motor weakness and ability to accomplish tandem gait (walk
on a straight line), which may be compromised in myelopathy
or cerebellar disorders.
Range of motion
A regional evaluation of the spine is part of the overall assessment.
The spine has four normal sagittal curves. There is a fixed sacral
kyphosis and a primary thoracic kyphosis that are apparent at
birth. Cervical lordosis develops when the infant can maintain an
upright head posture. The next curve, which typically develops
once a child starts to walk, is the lumbar lordosis. Between each
of the sagittal curves is a transition zone where alignment
is neutral relative to the vertical sagittal axis of the body. The
cervical spine is well balanced in the sagittal plane so that C1
and C7 should be centered over the weight-bearing axis, and a
plumb line should descend through T12 and continue caudally
through the anterior portion of S1. The cervical lordotic curve
normally ranges from 25 to 50 degrees with an apex at C4
(Fig. 3c.1).
Assessment of cervical ROM is important from a functional
and diagnostic perspective. ROM should be assessed with an
inclinometer and recorded during the examination. Inclinometers
can be mechanical or electronic, and the use of even a simple
home-made device is preferable to a guestimation. An incli-
nometer can easily be made by punching a small hole through
the center point of a protractor, passing a string through the hole
and through a washer (to act as a weight), and tying the string in
a loop. The loop of string indicates the degree of inclination on
the protractor scale. A plastic scoliosis protractor can be used or
a paper protractor downloaded from www.eece.ksu.edu/hkn/
files/protractor.pdf and pasted onto a card for use.
C1, C2, and C7 are atypical vertebrae with respect to
morphology and function, whereas C3 to C6 are commonly
described as typical cervical vertebrae. The atlantooccipital joint
acts as a pivot for the flexion/extension motion of the cranium,
with 13 degrees average flexion/extension and 8 degrees lateral
bending, allowing only a few degrees axial rotation.
6
The atlantoax-
ial complex (C1-C2) has a total axial rotation of approximately
80-90 degrees, coupled with a flexion and extension of approxi-
mately 10 degrees and minor lateral bending. The prominent
motion of the subaxial cervical spine is flexion/extension with
some segmental rotation, the latter being both facilitated and
constrained by the alignment of the apophyseal joints and the
presence of the uncinate processes. The C5-C6 interspace is gen-
erally found to have the greatest range of flexion and extension
motion of the subaxial spine.
6
Subtle secondary motion, or coupled motion, of the cervical
spine occurs in response to the primary motion. The coupled
pattern of the cervical spine occurs with motion in the axial,
sagittal, or coronal plane, for example, the direction of axial
rotation in the subaxial spine is such that the spinous processes
rotate into the convexity of the spine on side bending.
AROM is performed by the patient at the instruction of
the examiner and is one of the cornerstones in the determination
of functional limits, assessment of improvement, and demon-
stration of disability when evaluating permanent impairment.
5
AROM is performed by the patient alone on instruction by
Chapter 3c Physical examination 57
Table 3c.2 Red flags in cervical spine evaluation
Tumor Osteomyelitis Spinal cord compression Trauma
Age > 50 Intravenous drug abuse Bowel/bladder dysfunction Trauma in patient < 50 years
Cancer history History of immunosuppression Gait dysfunction, balance problems Low velocity trauma in patient > 50
Unexplained weight loss History of fever, night sweats Fine motor dysfunction, clumsiness Corticosteroid use
Nocturnal pain History of urinary tract infection Arm pain, weakness
or skin infection
Modified from Clinical Practice Guidelines, AHCPR.
the examiner. In passive range of motion (PROM), the patient is
assisted by the examiner to reach the maximum range. Often,
PROM allows for more ROM in all planes. In the absence of
pain, PROM can be performed to the anatomic barrier, whereas
AROM is typically hindered by a physiologic barrier created
by extant pathology or patterns of disuse not related to the pre-
senting symptoms. ROM of the cervical spine is performed by
having the patient rotate the head to the right and to the left.
End points of motion should be symmetric. The patient should
be able to bend the head to the right and left, as though attempt-
ing to touch the ear to the shoulder but keep the shoulder from
rising at the same time. This motion is also referred to as side or
lateral bending. Flexion/extension ROM is assessed by having
the patient flex or touch the chin to the chest and then extend or
bend the neck backward. Neck extension is generally restricted
and may be painful for patients with cervical stenosis or nerve
root compression, although the opposite may also occur. All
these motions should be recorded in degrees using a goniometer
Figure 3c.1 Lateral radiographs of the cervical spine of various individuals of different ages. Clockwise from top left: A 16-year-old girl with
normal cervical spine lordosis and normal disk space. A 46-year-old woman with mild loss of the normal cervical lordosis, noted in the mid-upper
cervical spine. A 51-year-old woman with multilevel cervical spondylosis manifesting as narrowing of the intervertebral disk spaces at C4-C5 and
C5-C6 with endplate changes and marginal osteophytes. A 73-year-old woman with advanced spondylosis and a frank reversal of the normal
cervical lordosis as a result of marked multilevel diskogenic degenerative changes.
or, preferably, an inclinometer. Spurlings test (see below) may be
administered at this time.
Palpation
While the patient is lying down, a thorough palpatory assess-
ment of muscle tension, tenderness, and tissue texture abnormal-
ities from spasm or contracture of the superficial anterior and
posterior musculature must be performed. The examination
of the neck with the patient seated and the examination of
the upper thoracic spine are often integrated. The sternocleido-
mastoid muscle runs obliquely from the mastoid process of
the skull to the lateral border of the sternal notch and may be
injured in sudden hyperextension injuries of the cervical spine.
The trapezius muscle originates from the inion and the spinous
processes from C1 (atlas) to T12 (last thoracic vertebra); it flares
out to insert on the clavicle, acromion, and spine of the scapula.
Spasm in this muscle can best be palpated on the lateral aspect
of the neck. The scalene muscles are palpable in the anterior
paratracheal area. They originate on the transverse processes
of the cervical vertebrae and insert bilaterally on the first and
second ribs. These muscles function to laterally flex the neck
(side bend) and help the attached ribs elevate during forced
inspiration. Within this region, three anatomic sites of neural
compression have been implicated in thoracic outlet syndrome:
between the anterior and middle scalenes, between the clavicle
and first ribs, and between the pectoralis minor and the upper
ribs. The levator scapula originates on the ribs posterior tuber-
cles and inserts on the upper medial border of the scapula.
This muscle is tender to palpation when in spasm. Anomalous
cervical ribs may be palpated and can be confirmed radiologi-
cally; they may be involved in thoracic outlet obstruction but
usually exist only as an anatomic anomaly.
The cervical spine has an abundant supply of superficial and
deep interconnected lymphatics to return the lymph to the
vascular compartment in the thorax. Palpation of the cervical
lymph nodes can elicit tenderness in adenopathy caused by tumor
or infection.
NEUROLOGIC EXAMINATION
The neurologic examination provides both direct and indirect
methods of determining damage to the spinal cord and nerves by
examination of their sensory, motor, and reflex distribution. The
aim is to identify an anatomic level for possible neurologic deficit.
Sensory examination and dermatome testing
The sensory component for each spinal nerve originates in a
dermatome, a segmental portion of the skin. Each cutaneous
innervation generally follows the distribution of the underlying
muscle innervation (Fig. 3c.2). However, there are exceptions
and variations to this generalization in the cervical spine. The
suboccipital nerve (dorsal ramus of C1) exits the spine between
the skull and C1 and has no cutaneous distribution. The dorsal
branch of C2 is the greater occipital nerve, which distributes
cranially upto provide sensation to the vertex of the scalp.
The lesser occipital nerve of the cervical plexus (ventral ramus of
C2) supplies sensation to the skin of the scalp behind the ear as
well as the skin of the ear. Pathologic conditions affecting the C2
nerve result in occipital neuralgia. The dorsal ramus of C3 (third
occipital nerve) distributes cutaneous sensation to the upper
neck and scalp. The dorsal rami (sensory) of C4-C6 provide sen-
sation to the posterior neck in a cephalad to caudal direction.
The cutaneous nerves of the upper limb, on the other hand,
are derived from branches of the brachial plexus, and thus each
one is comprised of more than one nerve root.
24
The dermatomal
pattern in the extremities is patterned on orderly embryologic
limb development. Clinical differentiation between dermatomal
sensory loss and a peripheral nerve deficit helps distinguish
cervical radiculopathy from other neurologic problems.
The upper lateral cutaneous nerve of the arm is the termina-
tion of the lower branch of the axillary nerve. Its cutaneous
distribution is the lower half of the deltoid muscle and the long
head of the triceps brachii. The sensory branches of the radial
nerve are the posterior cutaneous nerve of the arm that distrib-
utes to the middle third of the back of the arm, the posterior
cutaneous nerve of the forearm, and the superficial branch of the
radial. All the above arise from the posterior cord of the brachial
plexus. The lateral cutaneous nerve of the forearm distributes into
the lower lateral and the anterior surface of the arm. This nerve
is the cutaneous branch of the musculocutaneous nerve which
arises from the lateral cord of the brachial plexus. The medial cuta-
neous nerve of the arm provides sensation to the posterior
surface of the lower third of the arm, as low as the olecranon,
and the medial cutaneous nerve of the forearm covers the ulnar
aspect of the forearm down to the hand. These are sensory
branches of the ulnar which arises off the medial cord of the brachial
plexus. The shoulder receives its cutaneous sensation proximally
from the cervical plexus, specifically from the supraclavicular
nerves of C3 and C4.
Motor strength examination
The dorsal and ventral rootlets at each level unite to form a
mixed spinal nerve. The motor roots arise from the anterior horn
Chapter 3c Neurologic examination 59
Figure 3c.2 The cervical dermatomes are indicated. The C5 to T1
dermatomes are expressed in the upper extremity and develop as the
embryonic limb bud does, extending from the trunk.
cells and thus lie ventral to the sensory rootlets; they exit the
spinal cord through the foramen above the named cervical
vertebrae and carry their fibers to the striated muscles. Because
there are eight cervical nerves and seven cervical vertebrae, the
C8 nerve root exits below the C7 body. From C5 to T1, these
nerves separate and recombine to form the brachial plexus where
the fibers are reconfigured into trunks, divisions, and cords
before finally forming independent branches (Fig. 3c.3). The
resulting nerves are thus of mixed root origin and are named
musculocutaneous, axillary, radial, median, and ulnar, innervating
muscles in the upper extremity. Evaluation of the efferent
nerves is achieved by testing the muscles they innervate. Motor
strength is objectively evaluated using a six-point grading system
(Table 3c.3).
Testing begins with assessment of the patients breathing. The
phrenic nerve (C3-C5) is the motor nerve to the diaphragm,
although it also contains many sensory and sympathetic fibers.
If the patient is breathing adequately without the use of acces-
sory musculature, the diaphragm is functionally intact.
19
The C5 nerve root innervates the deltoid muscle, and along
with C6 it also innervates the biceps muscle. The C6 nerve root
also innervates the wrist extensors. The C7 motor distribution
includes the triceps muscle, the wrist flexors, and finger extensors.
These demonstrate the overlapping character of upper limb
innervation (Fig. 3c.4).
Reflex examination
Pathologic alterations in the basic stretch reflexes are important
findings in neurologic disease. Deep tendon reflexes are a mis-
nomer, because they are actually muscle stretch reflexes initiated by
excitation of the afferent muscle spindle fibers. These 1a afferent
fibers synapse directly onto the proximal dendrites and soma of
the motor neurone, completeing the reflex arc, resulting in a
reflex muscle contraction. These monosynaptic reflexes are help-
ful for localizing the level of pathology in the cervical spine or
nerve root and for differentiating a lower motor neuron lesion
from an upper motor neuron lesion. Although some examiners
grade the intensity of reflexes on a scale of 0 to 3, we believe
it is more realistic to grade them as absent or present, because
there are variable individual reactions to reflex testing. Deep
tendon reflexes can be influenced by age, metabolic factors, and
anxiety levels in the patient. Brisk, or hyperreflexic responses,
however, may be abnormal findings on reflex testing.
Typically, upper motor neuron lesions involve the spinal cord
and cause hyperreflexia. Lower motor neuron lesions depress
reflexes. For example, the nerve of C5 mediates the biceps reflex
and that of C6 can be tested through the brachioradialis
reflex and C7 through the triceps reflex (Table 3c.4 and Figs. 3c.5,
3c.6, and 3c.7).
Long-tract signs
After injury to the corticospinal tract of the spinal cord, abnor-
mal reflexes, or long-tract signs, can be elicited that are not
typically found in normal individuals. These reflexes suggest
the presence of lesions proximal to the anterior horn cells and
represent clinical signs of myelopathy. Below are select examples.
Clonus is elicited by the examiner rapidly dorsiflexing the

ankle and maintaining slight pressure while counting the pulsed
contractions on resistance. Greater than four beats of clonus
is considered abnormal.
Lhermittes sign (a.k.a. the barbers chair phenomenon) is a

symptom of radiating shock-like sensation down the back
with neck flexion.
Babinskis sign is an abnormal reflex elicited by stroking the

lateral border of the plantar surface of the foot with a blunted
pointy object, which elicits dorsiflexion of the great toe with
fanning and dorsiflexion of the small toes (Fig. 3c.8). A nor-
mal response is plantar flexion of all toes. A positive Babinski
sign indicates damage to the corticospinal tract or injury to
the spinal cord.
Oppenheims sign is indicative of disease of the pyramidal

tract and is performed by sliding the pointed back of the reflex
hammer up the crest of the tibia. A positive test elicits a
response similar to a positive Babinski sign; the great toe
extends whereas the small toes flex and splay.
Hoffmans sign is a pathologic reflex elicited by flicking

and flexing the distal phalanx of the patients middle finger.
When the sign is present, there is prompt adduction of the
thumb and flexion of the index finger on the ipsilateral side
(Fig. 3c.9).
Dorsal scapular n.
Suprascapular n.
Lateral
pectoral n.
Musculo-
cutaneous n.
Axillary n.
Radial n.
Median n.
Ulnar n.
L
a
te
r
a
l
P
o
s
te
r
io
r
M
e
d
i
a
l
To subscapularis
teres major
latissimus dorsi
Medial cutaneous
nerves to the arm
and forearm
Medial
pectoral n.
Long
thoracic n.
C4
C5
C6
C7
C8
T1
T2
Dorsal scapular n.
Suprascapular n.
Lateral
pectoral n.
Musculo-
cutaneous n.
Axillary n.
Radial n.
Median n.
Ulnar n.
L
a
te
r
a
l
P
o
s
te
r
io
r
M
e
d
i
a
l
To subscapularis
teres major
latissimus dorsi
Medial cutaneous
nerves to the arm
and forearm
Medial
pectoral n.
Long
thoracic n.
C4
C5
C6
C7
C8
T1
T2
Figure 3c.3 Diagram of the brachial plexus. There is a complex
interconnection of nerve tissue. Note the differentiation between the
nerve roots, which arise segmentally, and the ultimate peripheral
nerves, which are usually an amalgam of two or more nerve roots.
Table 3c.3 Evaluation of motor strength
15
5 - Normal
4 - Able to overcome moderate resistance (not symmetric to contralateral side)
3 - Able to accomplish full range of motion against gravity
2 - Able to accomplish full range of motion with gravity eliminated
1 - Only trace muscle contraction
0 - Flaccid
F
D
A
E
C
B
G
Figure 3c.4 Testing a full array of individual muscles permits the examiner to form an accurate assessment of the affected nerve roots and to
assess whether the injury is due to a specific peripheral nerve injury. Comprehensive examination is necessary because of the overlapping neural
supply to individual muscles. A: infraspinatus (suprascapular nerve; C5, C6): external rotation of the upper arm at the shoulder. B: deltoid (axillary
nerve; C5, C6): abduction of the upper arm. C: biceps brachii (musculocutaneous nerve; C5, C6) flexion of the supinated forearm. D: triceps
(radial nerve; C6, C7, C8): extension of the forearm at the elbow. E: bracioradialis (radial nerve; C5, C6): flexion of the forearm at the elbow with
the forearm in neutral rotation. F: extensor carpi ulnaris (posterior interosseous nerve; C7, C8): extension and abduction of the hand at the wrist.
G: extensor digitorum (posterior interosseous nerve; C7, C8): extension of the fingers at the metacarpophalangeal joints.
An inverted brachioradialis reflex is elicited by tapping the

brachioradialis tendon and observing ipsilateral finger flexion.
In the finger escape sign, the patient is asked to hold his or her
fingers in an extended and adducted position. If the two ulna-
most digits drift into abduction and flexion within 30-60 sec-
onds, the patient is deemed to have a positive finger escape sign.
In a grip and release test, the patient should be able to rapidly

make and release a fist 20 times within 10 seconds.
A scapulohumeral reflex is elicited by tapping the vertebral

border of the scapula at the tip of the scapula spine or the base
of the inferior angle. A normal response should be retraction
of the scapula by the rhomboid muscles (C4-C5). Absence of
retraction is abnormal.
A pectoralis reflex is an indication of hyperreflexia. The reflex

is present when tapping the pectoralis tendon elicits flexion
of the elbow or dorsiflexion of the wrist (Fig. 3c.10).
M
K
I
L
J
H
Figure 3c.4 Contd H: Flexor carpi radialis (median nerve; C6, C7): flexion and abduction of the hand at the wrist. I: abductor pollicis brevis
(median nerve; C8, T1) abduction of the thumb at right angles to the palm. J: flexor digitorum profundus I and II (anterior interosseous nerve; C7,
C8): flexion of the distal phalanges of the index and middle fingers. K: third and fourth palmer interossei (ulnar nerve; C8, T1): finger adduction by
the patient on the left as the examiner pulls a card. L: dorsal interosseous muscle (ulnar nerve; C8, T1): abduction of the fingers. M: abductor
digiti minimi (ulnar nerve; C8, T1): abduction of the little finger.
Figure 3c.6 The brachioradialis reflex is tested by a direct tap on the
muscle tendon.
Figure 3c.5 Biceps reflex: Support the forearm with the patients
elbow at a right angle and apply light tension to the biceps tendon with
your thumb, which should then be hit lightly with the reflex hammer.
Figure 3c.7 The triceps reflex can be more easily elicited if the arm
is supported so that the forearm hangs freely or by supporting the arm
in the horizontal gravitational plane.
Table 3c.4 Muscle nerve root origins
Upper extremities Root level tested Nerve foramen
Pectoralis C5-T1
Biceps C5-C6 C4-C6
Brachioradialis C5 C5-C6
Triceps C7 (C8) C6-C7
Specialized physical tests
The distraction test is an example of a provocative maneuver that
can relieve symptoms of spondylosis or radiculopathy. While
the patient is sitting or lying down, the palm of the examiners
dominant hand is placed under the base of the skull and the
nondominant hand placed under the chin. The head is gently
distracted, increasing the pressure to about 5-7 kg. A positive sign
provides symptomatic relief of neck or arm pain.
An axial compression test is a provocative maneuver intended
to elicit the neck or arm pain a patient may be experiencing
intermittently. This is performed by placing up to 5-7 kg of
pressure on the top of the head, preferably while the patient is
sitting. A positive response precipitates or increases the patients
symptoms. A distraction test can be performed after this test to
attempt to provide some relief.
Spurlings sign is a maneuver to provoke symptom radiation.
The patient laterally flexes and extends the neck (rotating the
head to the symptomatic side), after which the examiner applies
axial compression to the spine. A positive result causes pain or
tingling that starts on the ipsilateral side of the neck or shoulder
and radiates distal to the elbow (Fig. 3c.11). Spurlings test has
been shown to have a sensitivity of 30% and a specificity of 93%
when confirmed with electrodiagnostic studies.
17
Pronator reflex (a.k.a., ulnar reflex) is produced by tapping
the volar aspect of the distal radius, or alternatively the styloid
process of the ulna, with the forearm in a neutral position and
the elbow flexed. The normal response is forearm pronation and
adduction of the hand. The pronator reflex represents a muscle
stretch reflex of the pronator teres that would make it helpful in
evaluating C6 and C7 root lesions.
14
The Valsalva maneuver is a provocative test that exacerbates
arm pain when a patient bears down or coughs. These symptoms
result from the increase in intrathecal pressure.
Figure 3c.8 A positive or extensor plantar response, also known as a
Babinski sign. The sole is scratched from the lateral aspect of the heel
forward and then medially across the ball of the foot.
Figure 3c.9 Hoffmans sign is
positive or present if the act of flicking
(flexing) the distal phalanx of the index
or middle finger (black arrow) elicits a
flexion of the thumb (white arrow)
and/or other fingers.
Tests for thoracic outlet syndrome include maneuvers that
are presumed to tighten the thoracic outlet, such as arm hyper-
abduction, the elevated arm stress test, or the Adson test,
all of which may provoke the patients typical symptoms of pain
and/or paresthesia or affect the radial pulse. The Adson test,
also called Adsons maneuver, is performed with the patient
in a sitting position. The patients hands rest on the thighs,
the examiner palpates both radial pulses as the patient rapidly
fills his or her lungs by deep inspiration, and, holding his or
her breath, hyperextends the neck and turns the head toward
the affected side. If the radial pulse on that side is decidedly or
completely obliterated, the result is considered positive. In the
Allen test, which is sometimes also described in the literature as
the Adson test, the arm in which the patient is experiencing
symptoms is raised and rotated while the head is turned away
from the affected side. If the strength of the pulse is reduced in
either of these two tests, it indicates compression of the subcla-
vian artery.
All the above are nonspecific tests. If they are positive, however,
there may be an indication to perform further studies.
EVALUATING THE IMPACT OF NECK PAIN
The standard history and physical examination provide objective
findings that support subjective complaints to develop an
overall assessment of cervical spine disorders. This standard
examination does not often assess the impact of the disability
on a patients life quality. Functional scales can be potentially
useful to measure the impact of disease on the performance of
common daily activities. Defining a standard evaluation for
functional disability is difficult, because functional activity can
be influenced by many factors independent of symptoms and
signs such as age, psychologic ability to cope with disease, and
the demands of professional activity.
8
Well-validated instruments
for evaluating neck dysfunction are widely available (Table 3c.5).
For individual patient follow-up evaluation, the Patient-Specific
Chapter 3c Evaluating the impact of neck pain 65
Figure 3c.10 Position of the examiners fingers over the pectoralis
tendon to test for a pectoralis reflex.
Figure 3c.11 Spurlings test: Hold the patients neck in extension
for a few moments. Typical symptoms of brachialgia may be elicited,
and if not, the test can be augmented by adding a lateral tilt of the
head toward the symptomatic side as shown above. These maneuvers
increase the degree of foraminal compression.
Functional Scale has high sensitivity to change and thus repre-
sents a good choice for clinical use.
16
The MOS 36-Item Short Form Health Survey (SF-36),
developed for the Medical Outcomes Study, is an example of a
traditional scale for functional assessment.
20
This questionnaire
has demonstrated an overall usefulness in the general reporting
of musculoskeletal ailments; however, it does not report on
specific neck pain or disability. The Neck Disability Index is a
10-item questionnaire designed to assess pain-related limitations
in activities of daily living. The test is scored as a percentage of
maximal pain and disability. The scale is categorized by activity;
however, some questions are not pertinent for all patients. The
Copenhagen Neck Functional Disability Scale is a 15-item ques-
tionnaire requiring yes, no, or occasional as responses. The
Northwick Park Neck Pain Questionnaire has nine five-part ques-
tions requiring responses of 0-4. The Patient Specific Functional
Scale is unique in that it requires the patient to generate a spe-
cific list of problems emphasizing the limitations most affecting
the patient. The Neck Pain and Disability Scale is a unique
20-item questionnaire in which a visual analog scale is assigned
to each discomfort. The 20 items measure intensity of pain and its
interference with the vocational, recreational, social, and func-
tional aspects of living and the impact of emotional factors.
SPECIAL TESTS
Imaging studies of the spine
After the development of a working pathologic and anatomic
diagnosis, appropriate imaging studies should be selected to
demonstrate and confirm the diagnosis. Routine spinal imaging
is not recommended during the first month of symptoms except
in the presence of red flags.
Radiographs
Plain radiography is the most widely available modality for imaging
the cervical spine. The cervical (C) spine series consists of anteropos-
terior and lateral views to visualize the entire cervical spine and an
open-mouth odontoid view to assess the odontoid and C1-C2 joint
(Figs. 3c.12 and 3c.13). A swimmers view may be required to assess
the cervicothoracic junction if the C7-T1 level is obscured by the
patients shoulders on the lateral cervical radiograph. Lateral flexion
and extension radiographs should also be obtained in patients
with a history of trauma and patients with extensive degenerative
disease. These radiographic views permit assessment of cervical
alignment, degenerative changes, assessment of bony architecture
in the vertebral bodies, and gross evaluation of the soft tissues.
Oblique radiographs can be used to assess encroachment of the
neural foramina (Fig. 3c.14). Radiographs should be the first-line
diagnostic modality for patients presenting with neck pain when
any of the following red flags are present: recent significant trauma
or recent mild trauma in patients over 50, prior cancer or recent
infection, neck pain worse at night or worse with rest, and history
of intravenous drug abuse or corticosteroid use.
Radiographs are the least sensitive of the imaging modalities
in predicting symptomatology once tumor, trauma, or infection
is excluded. A cervical sprain or strain leave no direct radiographic
Table 3c.5 Standard instruments for evaluating
neck dysfunction
Medical Outcomes Study 36-Item Short Form Health Survey
Neck Disability Index
18
Copenhagen Neck Functional Disability Scale
12
Northwick Park Neck Pain Questionnaire
13
Patient Specific Functional Scale
22
Neck Pain and Disability Scale
23
Figure 3c.12 Lateral and anteroposterior radiographs of the cervical spine of a 34-year-old patient who had a disk herniation at C6-C7 with a clinical
radiculopathy. The plain lateral film shows narrowing of the C5-C6 disk space (arrow) with a bony bar between the two vertebrae. That was not
appreciated on the MRI. Note also the loss of cervical lordosis. The C5-C6 uncovertebral joint is indicated by an arrow on the anteroposterior radiograph.
evidence, nor does a herniated disk. Although the presence
of degenerative disk disease can be visualized on radiographs,
it cannot predict symptoms or disability status.
9
As much as
25% of the population has radiographic degenerative changes
by age 50, and 75% have degenerative changes by age 70.
7
It is
the strength of this literature that persuades against the use of
routine cervical spine radiographs alone to evaluate disability.
Computed tomography
Computed tomography (CT) is a noninvasive diagnostic modal-
ity that provides excellent visualization of the cervical bony
anatomy, helps evaluate osseous pathology, and assesses the
integrity of the spinal canal. When CTs are supplemented with
myelography, one can also evaluate soft tissue structure and
impingement of nerve elements. That being said, studies directly
comparing magnetic resonance imaging (MRI) and CT myelo-
gram with respect to identifying pathology can yield conflicting
results. However, general consensus points to the advantage of
the CT myelogram in identifying osseous pathologies such as
fractures, osteophytes, and bony foraminal encroachment. MRI
studies better demonstrate soft tissue impingement, spinal cord
edema, and myelomalacia. The ability of current multiplanar CTs
has greatly enhanced the detail of the spine but also escalates the
risk of false positivity. Scans can be reconstructed electronically
in any desired plane to better visualize pathoanatomy (Fig. 3c.15).
Chapter 3c Special tests 67
Figure 3c.13 Open mouth view: A frontal view of the atlantoaxial
(C1-C2) joint can be obtained radiographically with the patients mouth
open as the teeth no longer obscure the direct view. In this example,
both right and left C1-C2 facet joints are clearly seen, the dens is
clearly visualized equidistant from both facet joints, and a partial view
is even obtained of the occipitocervical articulations.
Figure 3c.14 Oblique cervical radiograph: The right-sided neural
foramina can be clearly visualized. The black arrow indicates the right
C4-C5 intervertebral or neural foramen; the C5 nerve root traverses
the foramen. The small osteophytes arising from the right C3-C4
uncovertebral joint (joint of Luschka) are identified by the white arrow.
The mild foraminal stenosis can be appreciated when comparing the
foraminal dimensions with the normal adjacent foramina.
Figure 3c.15 Midsagittal reconstructions of the cervical spine of a
56-year-old man who has an os odontoideum. Note the very short dens
(odontoid process) that results in multiplanar atlantoaxial instability.
The anterior ring of C1 (arrow) is normally aligned in neutral; there is
posterior C1-C2 subluxation in the extended position and marked
anterior C1-C2 subluxation in flexion. Note the marked anterior
reposition of the C1 ring in flexion resulting in the posterior arch of C1
approaching the C2 body and causing severe spinal stenosis.
Three-dimensional multiplanar CTs are extremely useful to
demonstrate the complex anatomy of fractures and spinal defor-
mity, be it congenital or other (Fig. 3c.16).
Magnetic resonance imaging
MRI uses radiofrequency pulses within a strong magnetic field
to produce an image without the use of ionizing radiation.
MRI is a potentially useful modality for evaluating spinal cord
pathology in the presence of brachialgia. MRI is also an excellent
imaging modality to assess the soft tissues in the cervical spine
and their contribution to compression of the nerves and spinal
cord (Figs. 3c.17, 3c.18, and 3c.19). MRI provides excellent
visualization of the spinal cord for masses or lesions and cysts
as well as for the myelomalacia seen in chronic compression
and edema seen in various acute pathologies. Spinal pathology,
such as diskitis or local abscess, can be well identified with MRI.
However, many of the abnormalities seen on MR images may
be incidental, resulting in the potential for over-diagnosis.
Nevertheless, in the presence of many of the red flags for pathol-
ogy, MRI provides indispensable information that can rapidly
help confirm or rule out serious clinical problems.
Myelography
Myelography uses nonionic contrast injected intradurally to
indirectly visualize soft tissues in the canal. Filling defects are an
indicator of spinal cord or nerve root compression. Plain myelo-
graphy is typically enhanced with the addition of a CT. Myelography
is a good test for patients in whom spinal root or cord compres-
sion is suspected and for patients who have received metallic
Figure 3c.16 Three-dimensional reconstruction of the cervical spine
of a child with a congenital hemivertebra (arrow). There is also a split
or butterfly vertebra at C5.
B A
Figure 3c.17 Cervical magnetic resonance imaging (MRI) of a 26-year-old woman who has a large C6-C7 disk herniation. (A) Sagittal MRI. (B)
The axial image through the C6-C7 disk (D) shows the large herniation (H) and the compressed spinal cord (SC).
implants, which render an MRI ineffective. Myelographic studies
also permit acquisition of (dynamic) images of the spinal cord and
nerves taken with the neck flexed, extended, laterally tilted, or
rotated (Fig. 3c.20). Soft tissue or bony impingement on the neural
elements may be demonstrated in positions other than neutral.
Note that there are now MRI scanners that also permit a full range
of movement and the opportunity to obtain dynamic scans.
Barium swallow
Visualizing swallowed radiographic contrast fluoroscopically
can demonstrate mechanical compression on the esophagus from
anterior osteophytes and differentiate dysphagia from other
pathologies.
Bone scans
A bone scan uses the technique of scintigraphy (diagnostic tech-
nique of recording the distribution and uptake of radioisotopes
injected into various body systems) to gauge the chronicity of a
bony lesion such as a fracture, neoplasm, or a focus of osteomyelitis
and to monitor disorders affecting bones. Scintigraphy is a very
sensitive imaging modality; however, it is not very specific. The
bone scan detects the distribution of a radioactive agent injected
throughout the venous system. After injection, a scintillation
camera detects the radioisotopes distribution in the body, most
importantly its concentration in the skeleton. Areas of increased
metabolic activity are imaged as increased isotope uptake on a
full body scan.
Electrodiagnostic studies
Examination by electrodiagnostic methods is useful to docu-
ment radiculopathy and to confirm nerve root impingement.
These studies additionally facilitate the diagnosis of peripheral
Chapter 3c Special tests 69
B
A
Figure 3c.18 Cervical magnetic resonance imaging (MRI) of a 34-year-old woman who had a left C7 radiculopathy. (A) Midsagittal and
parasagittal MRIs show the apparently small disk herniation. (B) Axial MRI at C5-C6 demonstrates normal anatomy, whereas at C6-C7 there is a
large disk herniation (white arrow) extending into the left neural foramen and compressing the C7 nerve root. Note the normally patent right-sided
neural foramen.
entrapment syndromes and peripheral neuropathy. The tests
commonly include needle electromyography, nerve conduction
studies, and somatosensory evoked potentials.
Electromyography
Measuring the electrical activity of muscle fibers at rest and
when active provides diagnostic information on the degenerative
or healthy status of muscles and their innervation and distin-
guishes neurogenic from myopathic disorders. The electromyo-
graphic evaluation in chronic cervical radiculopathy shows a
partial denervation pattern that manifests as increased amplitude
and a longer duration of the motor unit potential. Fibrillations,
or small-amplitude, single muscle fiber potentials, may also be
present but are nonspecific and usually seen in the acute stage.
Insertional activity from movement of the electrode is normal
in electromyographic studies, but if it persists after electrode
motion ceases, it is described as prolonged insertional activity
and can be a sign of radiculopathy. When these tests are done
within the first 2-3 weeks after injury, the results are falsely neg-
ative as it takes time to develop denervation.
B
A
Figure 3c.19 Cervical magnetic resonance imaging (MRI) of a 51-year-old man who had cervical myelopathy. (A) The sagittal scans show
multilevel spinal stenosis. T1- and T2-weighted scans are shown. (B) Axial scans through the disks show central spinal stenosis from C3-C4 to C6-
C7 with spinal cord compression.
Nerve conduction studies
Using nerve conduction studies to evaluate how well nerves
transmit electrical signals provides an assessment of the overall
condition of both individual nerves and whole nerve structures.
Measured electrical parameters are usually the signal amplitude
and signal onset latency. These measured values are then com-
pared with established normal parameters to determine the site
of a compression. Nerve conduction studies are useful to evalu-
ate acute and chronic peripheral entrapment neuropathies that
mimic radiculopathy. Nerve conduction velocity and latency
changes are not typically found in cervical radiculopathy unless
there is extreme demyelinization of axons.
The F-wave response tests electrical conduction through
motor roots (Table 3c.6). The F-wave is recorded after maximal
stimulation of a motor nerve. The amplitude, shape, and latency
should change with each stimulation. Clinical parameters usually
evaluated are response time, or latency. Because the F-wave is
dependent on the integrity of the entire motor unit, it can assess
proximal neuropathies.
Another parameter with which to document nerve abnormalities
is through the recording and measurement of sensory nerve action
potentials. Abnormal sensory nerve action potentials are noted
with damage to the nerve from the dorsal root ganglion while they
are normal in pure radiculopathy, as the presumed lesion is
proximal to the sensory ganglion. In patients with sensory deficit
in the hands, recordings of sensory nerve action potentials make
a differentiation between lesions of dorsal roots and peripheral
nerves possible.
Somatosensory evoked potentials
Somatosensory evoked potential recordings can be used to
evaluate the integrity of the central nervous system and peripheral
sensory neurons. Because most peripheral nerves in the upper
extremity carry fibers from multiple roots, somatosensory evoked
potentials are not specific in elucidating spinal root dysfunction
but can be useful in determining spinal cord abnormality that
affect cord pathways.
Laboratory screening
Laboratory studies provide valuable clinical evidence for patients
presenting with atypical neck complaints or those suspected of
tumor or infection. A complete blood count with differential can
help detect a response to infection, blood dyscrasias, and medica-
tion side effects.
The erythrocyte sedimentation rate and C-reactive protein are
categorized as acute phase reactants commonly used in ortho-
pedics to detect evidence of an infection or a connective tissue
disorder. Although both indices serve the same primary function,
clinicians often use them simultaneously, because the C-reactive
protein is quicker to respond to either improvement or wors-
ening of a clinical course. A comprehensive metabolic panel,
including Ca
+
, phosphorus, uric acid, alkaline phosphatase, and
acid phosphatase, can help detect metabolic bone disease.
CONCLUSION
Evaluation of the cervical spine in workplace injuries requires a
multidimensional workup that facilitates, first, ruling out serious
pathology before initiating therapy for the work-related injury
and, second, evaluation of the patients work setting relative to
the patients recovery process for a rapid and safe return to work
activity. The trend in evaluating cervical spine injuries increas-
ingly involves more emphasis on EBM to guide treatment. Using
EBM as a guide facilitates a rapid evaluation with concise
elimination of red flags for spinal pathology. Returning to work
Chapter 3c Conclusion 71
B A
Figure 3c.20 Cervical myelogram. (A) Lateral (left) and anteroposterior (right) views of the cervical spine of a 56-year-old man with neck and arm
pain and early signs of cervical myelopathy. Compression of the thecal sac is well seen on the lateral view at the C4-C5 and C5-C6 levels when his
neck is extended. The anterior-posterior view demonstrates a paucity of contrast at those levels and truncation of the exiting nerve roots. Normal
nerve root filling is noted at C6-C7 and distal levels. (B) Postmyelogram axial computed tomography images clearly demonstrate bilateral foraminal
stenosis at C4-C5, whereas at C6-C7 the nerve root sleeves can be seen to fill well with the contrast (arrow).
activity or to normal daily activities, in general, is therapeutic;
if necessary, they can be modified to minimize exacerbations
and maximize productivity. Once neck pain shifts from acute to
subacute or chronic, there exists a comprehensive panel of tests
and studies that help to continue to delineate pathology and
further guide patient treatment.
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Table 3c.6 Nerve and main root supply of muscles
Spinal roots See Figure 4
Spinal accessory nerve
Trapezius C3, C4
Brachial plexus
Rhomboids C4, C5
Serratus anterior C5, C6, C7
Pectoralis major
Clavicular C5, C6
Sternal C6, C7, C8
Supraspinatus C5, C6
Infraspinatus C5, C6 A
Latissimus dorsi C6, C7, C8
Teres major C5, C6, C7
Axillary nerve
Deltoid C5, C6 B
Musculocutaneous nerve
Biceps C5, C6 C
Brachialis C5, C6
Radial nerve
Long head
Triceps Lateral head C6, C7, C8 D
Medial head
Brachioradialis C5, C6 E
Extensor carpi radialis longus C5, C6
Posterior interosseous nerve
Supinator C6, C7
Extensor carpi ulnaris C7, C8 F
Extensor digitorum C7, C8 G
Abductor pollicis longus C7, C8
Extensor pollicis longus C7, C8
Extensor pollicis brevis C7, C8
Extensor indicis C7, C8
Median nerve
Pronator teres C6, C7
Flexor carpi radialis, C6, C7 H
Flexor digitorum superficialis C7, C8, T1
Abductor pollicis brevis C8, T1 I
Flexor pollicis brevis C8, T1
Opponens pollicis C8, T1
Lumbricals I and II C8, T1
Anterior interosseous nerve
Flexor digitorum profundus I and II C7, C8 J
Flexor pollicis longus C7, C8
Ulnar nerve
Flexor carpi ulnaris C7, C8, T1
Flexor digitorum profundus III and IV C7, C8
Hypothenar muscles C8, T1
Adductor pollicis C8, T1
Flexor pollicis brevis C8, T1
Palmar interossei C8, T1 K
Dorsal interossei C8, T1 L
Lumbricals III and IV C8, T1
Abductor digiti minimi C8, T1 M
Adapted from Medical Research Council: Aids to the examination of the peripheral
nervous system. London, 1980, Her Majestys Stationary Office.
C HA P T E R
3d
Treatment Options
for Disorders of the
Cervical Spine
James N. DeBritz and Sam W. Wiesel
As with any pathophysiologic condition, treatment of neck
pain depends on the proper diagnosis. Neck pain has multiple
etiologies (Table 3d.1) that may result from trauma as well as
from chronic atraumatic conditions. Understanding these etiolo-
gies requires detailed knowledge of both the anatomy of the
cervical spine and its relationship to neurovascular structures as
well as comprehension of the natural history of cervical spondy-
losis and myelopathy. Diagnosis of neck pain can be more easily
accomplished by dividing clinical complaints into several main
categories, including axial neck pain, neck pain with an asso-
ciated radiculopathy, and neck pain with signs and symptoms of
myelopathy. Once the proper diagnosis is established, treatment
can be directed in a focused and individualized manner.
This chapter summarizes some of the most common cervical
spine disorders to aid in their diagnosis. The reader is instructed
on how a pertinent history, directed physical examination, and
diagnostic findings can be used to establish a diagnosis. Treatment
options are discussed in detail, and finally a diagnostic and
treatment algorithm is presented that integrates the information
into a usable format.
ANATOMY
A detailed understanding of the osseous and soft tissue structures
of the neck is a prerequisite to fully understand the pathophysi-
ology of neck pain and cervical spine disease. Once a pathologic
process temporarily or permanently distorts the normal anatomy
of the neck, a compensatory response may occur that often
presents to the individual as pain.
With the exception of C1, each cervical vertebra articulates
with the adjacent vertebra through the facet, or zygapophyseal,
joints. These are gliding joints characterized by capsules and
synovial membranes in addition to ligamentous support. The
facet joints are innervated by the dorsal ramus of the associated
nerve roots. Axial neck pain can be produced by facet joint
injections in asymptomatic individuals, providing evidence that
it can originate from the facet joints themselves.
2
This informa-
tion can be used to direct treatment in certain cases, as discussed.
The amphiarthrodial joints that join each vertebral body
through intervertebral disks play an important role in the patho-
logic process of the spine as well. Although varying in size
depending on the level of the spinal column, all intervertebral
disks are identical in their structural organization. The internal
portion of the disk is comprised of the nucleus pulposus that
is contained around its periphery by the annulus fibrosus.
Table 3d.1 Causes of neck and neck-related
pain syndromes
Localized neck disorders
Osteoarthritis (apophyseal joints, C1-C2-C3 levels most often)
Rheumatoid arthritis (atlantoaxial)
Juvenile rheumatoid arthritis
Sternocleidomastoid tendinitis
Acute posterior cervical strain
Pharyngeal infections
Cervical lymphadenitis
Osteomyelitis (staphylococcal, tuberculosis)
Meningitis
Ankylosing spondylitis
Paget disease
Torticollis (congential, spasmodic, drug involved, hysterical)
Neoplasms (primary or metastatic)
Occipital neuralgia (greater and lesser occipital nerves)
Diffuse idiopathic skeletal hyperostosis
Rheumatic fever (infrequently)
Gout (infrequently)
Lesions producing neck and shoulder pain
Postural disorders
Rheumatoid arthritis
Fibrositis syndromes
Musculoligamentous injuries to the neck and shoulder
Osteoarthritis (apophyseal and Luschka)
Cervical spondylosis
Intervertebral osteoarthritis
Thoracic outlet syndromes
Nerve injuries (serratus anterior, C3-C4 nerve root, long thoracic nerve)
Lesions producing predominantly shoulder pain
Rotator cuff tears and tendinitis
Calcareous tendinitis
Subacromial bursitis
Bicipital tendinitis
Adhesive capsulitis
Reflex sympathetic dystrophy
Frozen shoulder syndromes
Acromioclavicular secondary osteoarthritis
Glenohumeral arthritis
Septic arthritis
Tumors of the shoulder
Lesions producing neck and head pain with radiation
Cervical spondylosis
Rheumatoid arthritis
Intervertebral disk protrusion
Osteoarthritis (apophyseal and Luschka joints, intervertebral disk,
osteoarthritis)
Spinal cord tumors
Cervical neurovascular syndromes
Cervical rib
Scalene muscle
Hyperabduction syndrome
Rib-clavicle compression
From Wiesel SW; Neck pain, ed 2. Charlottesville, VA, 1992, The Michie Company, pp. 60-61.
Both the nucleus pulposus and the annulus fibrosus share a sim-
ilar composition and are comprised mainly of water, proteogly-
cans, and collagen. They differ, however, in their organization
and in the type of collagen present. Type II collagen is found in
the nucleus pulposus, and type I collagen is present in the annu-
lus. The cervical intervertebral disks are wedge-shaped to accom-
modate the uncinate processes and the corresponding joints of
Luschka, a bony articulation between the vertebral bodies.
The blood supply and innervation of the intervertebral disks
of the cervical spine have been well defined. Branches of the
sympathetic plexus and the ventral nerve root form the sinuver-
tebral nerve that innervates the intervertebral disk, supplying
portions of the annulus, the posterior longitudinal ligament, the
periosteum of the vertebral body and pedicle, and the adjacent
epidural veins (Fig. 3d.1). In a review of clinical findings of
cervical diskography, Grubb and Kelly
5
showed a correlation
between reliable patterns of pain and each cervical disk. These
pain patterns and axial pain patterns produced by facet joint
injections are summarized in Figures 3d.2 and 3d.3, respectively.
In addition to the major articulations of the cervical spine
and their innervations, the soft tissue structures of the cervical
spine and the neck play an important role in neck pain. The
vertebrae are bound together by many ligaments. The anterior
longitudinal ligament and the weaker posterior longitudinal
ligament bind the vertebral bodies along the anterior and poste-
rior surfaces, respectively, and run from the skull to the sacrum.
The segmental denticulate configuration and intricate associa-
tion with the intervertebral disk is characteristic of the posterior
longitudinal ligament, and a prolapsed nucleus pulposus is most
likely to be permitted lateral to these expansions. The ligamentum
flavum is a strong elastic ligament that connects the laminae of
each of the vertebrae and runs from C2 to the lumbosacral interval.
A continuation of the supraspinous ligament, the ligamen-
tum nuchae, runs from C7 to the occiput and along with the
interspinous and intertransverse ligaments serves to stabilize
further the spinal column architecture.
Muscles in the neck are divided into anterior and posterior
groups. Anterior muscles are comprised mainly of the strap
muscles and the sternocleidomastoid. The neck musculature
forms several distinct layers posteriorly. From dorsal to ventral
Chapter 3d Treatment options for disorders of the cervical spine 74
Figure 3d.2 Axial pain patterns provoked during discography at each
cervical level. A: level between second and third cervical vertebrae;
B: level between third and fourth cervical vertebrae; C: level between
fourth and fifth cervical vertebrae; D: level between fifth and sixth
cervical vertebrae; and E: level between sixth and seventh cervical
vetebrae. (From Rao R: Instr Course Lect 84A(10):1872-1881, 2002.)
Figure 3d.1 Cross-sectional view showing the cervical nerve
root, dorsal and ventral primary rami, recurrent meningeal or
sinuvertebral nerve, and sympathetic plexus. Note the proximity
of the disc space, vertebral artery, and facet joints. (From Rao R:
Instr Course Lect 84A(10):1872-1881, 2002.)
are the trapezius and levator scapulae, splenius and longissimus,
semispinalis, and suboccipital muscles. These muscles assist in
scapular rotation (trapezius and levator scapulae) and rotation,
flexion, and extension of the neck. Strain of these muscles can
also contribute to neck pain.
NECK SPRAIN
The condition of nonradiating neck pain with a concomitant
loss of motion has been referred to incorrectly as neck sprain.
Correctly termed cervical strain and one of the most common
neck disorders, this often occurs in the absence of a distinct
traumatic episode. Most commonly, the pain is located in the
middle to lower part of the neck, and although the pain is not
secondary to trauma, its onset can be acute. The pain associated
with cervical strain is often a dull ache that is exacerbated by
movement. In addition, a component of referred pain may be
involved. This is not, however, true radicular pain secondary to
mechanical compression of a nerve root. The pain is referred
generally to other mesenchymal structures derived from a
similar sclerotome during the process of embryogenesis. The
most common referral patterns include the posterior of the
shoulder, the occipital area, the scapular region, and the anterior
chest wall, also known as cervical angina pectoris. The source of
the pain is most commonly believed to be the ligaments and
musculature of the cervical spine.
14
As previously illustrated,
however, both facet and disk disease can contribute to axial
neck pain and should be considered as a source of the inciting
complaint (Figs. 3d.2 and 3d.3).
Once the precise location, frequency, and quality of the pain
have been determined, careful questioning should then address
the presence, if any, of subtle long-tract signs, including bowel
or bladder dysfunction and gait abnormalities, to avoid missing
the diagnosis of myelopathy. Physical examination of the patient
will usually reveal only some local tenderness lateral to the
bony spine. The loss of motion in individual patients is variable
and tends to correspond directly with the intensity of the pain.
True muscular spasm, defined as continuous muscular contrac-
tion, is rare, except in severe cases of torticollis in which the head
is tilted to one side.
Because radiographic studies in neck strain are usually normal,
plain films are generally not warranted on the first office visit. If
the pain persists for more than 2 weeks, however, a radiograph
should be obtained to rule out other more serious causes of neck
pain such as instability or neoplasia.
Treatment
The prognosis for patients with cervical strain is excellent because
the natural history of this disorder is complete resolution of all
symptoms over a period of several weeks. Therapy consists
primarily of rest and immobilization, often with the use of a soft
cervical orthosis. Certain medical interventions such as antiin-
flammatory agents and/or muscle relaxants may aid in the acute
phase of pain management, but they do not appear to alter the
natural course of the syndrome.
Although no good randomized, prospective, clinical trials
have studied their efficacy, trigger point injections do seem
empirically to work well. The purpose of a trigger point injection
is to decrease inflammation in a specific anatomic area, with
apparently superior results the more localized the trigger point.
These injections can be repeated at 1- to 3-week intervals.
ACUTE HERNIATED DISK
A herniated disk results when the nucleus pulposus protrudes
through the fibers of the surrounding annulus fibrosus and
occurs around the fourth decade of life while the nucleus pulpo-
sus remains gelatinous. Stookey
15
and Rothman and Marvel
13
described three types of soft disk herniations (Fig. 3d.4), with
the posterolateral herniation being the most common due to the
anatomy of the posterior longitudinal ligament, as previously
mentioned. Herniations occurring posterolaterally produce
predominantly motor signs and symptoms. As opposed to those
in the lumbar region, disk herniations occurring centrally may
cause myelopathy because of the presence of the cord in the
cervical region.
The most common levels for herniation are at the C6-C7
and C5-C6 levels. Those at the C7-Tl and C3-C4 levels are
uncommon, and those at the C2-C3 level are extremely rare.
Interestingly, not every disk herniation is symptomatic. The pres-
ence and severity of symptoms depend on the individuals spinal
reserve capacity, the presence or absence of associated inflamma-
tion, the size of the herniated fragment, and the presence of con-
comitant disease processes such as uncovertebral joint osteophytes.
In general, a herniated disk affects the nerve root of the
next lowest cervical level: A C3-C4 disk affects the C4 nerve
root, a C4-C5 disk affects the C5 nerve root, and so on. The
radicular symptoms then correspond to the involved nerve root.
In addition, as previously stated, a herniated disk may cause
some long-tract signs because of the presence of the spinal cord
at the cervical level.
Chapter 3d Acute herniated disk 75
Figure 3d.3 Composite map of axial pain patterns produced by
injections into the facet joints at the second through seventh cervical
levels. (From Rao R: Instr Course Lect 84A(10):1872-1881, 2002.)
Most patients have symptoms consisting primarily of arm
pain. Although it may begin in the neck region, the pain radiates
down into the shoulder, arm, forearm, or hand along a clearly
defined dermatome. The onset of pain may be gradual, although
acute tearing or snapping sensations may occur. The arm pain
may vary in intensity from a dull cramping pain in the arm with
use to pain so severe as to preclude use. In addition, attacks of
sharp pain may radiate into the hand and fingers with associated
paresthesias. Pain severe enough to awaken the patient at night
is common.
The differential diagnosis of radicular pain must be considered.
Pathologies that range from tumors to nerve entrapment syn-
dromes share the common trait of mechanically compressing
a nerve root and imitating radicular symptoms. Other neuro-
logic diseases can masquerade as a radicular process, however,
and should also be contemplated. Classic differential diagnoses
include a Pancoast tumor, which is an apical lung tumor often
accompanied by Horner syndrome because of disruption of the
sympathetic chain, and thoracic outlet syndrome, which can be
diagnosed on physical examination.
Physical examination may reveal some decreased motion of
the neck that may be so severe as to manifest as frank torticollis.
Any maneuver (such as the Valsalva maneuver) that stretches
the involved nerve root may recreate the pain pattern. Spurlings
test, in which the neck is extended, may often make the pain
worse by further narrowing the involved intravertebral foramina.
Additionally, coughing, shoulder abduction, and axial compres-
sion tests are often positive in patients with compression radicu-
lopathy. The axial compression test is performed by pressing
down on a patients head while he or she is either sitting or
lying down. A positive finding consists of worsening or repro-
duction of radicular symptoms. The shoulder abduction relief
test is positive if radicular symptoms are decreased when a seated
patient elevates one hand above the head with the elbow flexed
and the shoulder abducted to 90 degrees. An axial manual trac-
tion test is performed with the patient supine. A positive finding
consists of a decrease or complete absence of radicular symptoms
when 20 to 30 pounds of axial traction is applied.
The finding of a neurologic deficit on physical examination
greatly aids in the diagnosis, although in the setting of a chronic
radiculopathy, the neurologic examination may be normal.
Because subjective sensory changes are often difficult to inter-
pret, the neurologic examination must show a diminution of
reflexes, motor weakness, or atrophy to be significant.
Henderson et al
6
found a diminished deep tendon reflex in
71% and a demonstrable motor deficit in 65% of 846 patients
with cervical radiculopathy.
The specific motor and deep tendon reflex changes noted
depend on the cervical nerve root that is compressed by the
herniated disk. Because the C3 and C4 nerve roots do not have
a uniquely testable reflex or motor innervation, involvement
of these roots corresponds to sensory changes in their respective
dermatomes. The remaining cervical nerve roots do exhibit
testable motor and reflex changes in addition to sensory deficits
in their corresponding dermatomes (Table 3d.2). The specific
motor innervation of the individual nerve roots allows the
examiner to pinpoint the level of disease with good accuracy.
Because plain films are most often normal they are nondiag-
nostic, leaving the clinician to rely on the history and physical
examination to arrive at the diagnosis of an acute herniated
cervical disk. Occasionally, disk space narrowing is seen at the
involved interspace, or oblique films may show foraminal
narrowing. Plain films are useful primarily for ruling out other
causes of arm and neck pain, such as instability and neoplasia.
Other diagnostic tests, such as electromyography (EMG) or
myelography, are not useful as screening tests and should be
Figure 3d.4 Types of soft disk herniations. (From Boden SD, et al:
The aging spine: essentials of pathophysiology, diagnosis, and treatment.
Philadelphia, 1991, WB Saunders.)
used more to confirm diagnoses based on a detailed history
and physical examination. In addition, the routine use of com-
puted tomography (CT) or magnetic resonance imaging (MRI)
is not warranted. These sensitive studies may reveal herniated
disks that are clinically insignificant: In a study of 63 asymp-
tomatic individuals, 10% showed evidence of cervical disk
herniation on MRI.
1
Treatment
The primary mode of treatment for an acute herniated disk is rest
and immobilization. A cervical orthosis greatly improves the
chance that the patient will remain at rest. The collar must fit
properly and hold the head in a neutral to slightly flexed posi-
tion. If the neck is held in hyperextension, the patient often is
uncomfortable and therefore noncompliant in its use. Once
the acute pain starts to subside, the patient should be weaned
slowly from the orthosis and should likewise increase activity
gradually. If the patient complies with the rest and immobiliza-
tion, the use of analgesics is often not necessary, although a brief
course of analgesic medicine may occasionally be required in
severe cases. Benzodiazepines and muscle relaxants can act as
central nervous system depressants but as such have a limited
role in the treatment of acute herniated disk disease.
Drug therapy does, however, have an important role in com-
bination with rest and immobilization. Evidence now suggests
that herniated disks are capable of eliciting an immune response
characterized by the secretion of cytokines such as interleukin-1,
interleukin-6, nitric oxide, and prostaglandins, which have mul-
tiple effects on tissues, including direct stimulation of nerve
ending and sensitization of nociceptors.
7
By inhibiting the pro-
duction pathway of some of these mediators, antiinflammatory
medications such as nonsteroidals have a role to play in sympto-
matic relief. Many such medications can have adverse gastroin-
testinal side effects but can generally be well tolerated for brief
periods. The patient should be educated on these side effects,
however, and should be instructed to stop taking the medication
immediately if side effects occur. Routine use of oral systemic
steroids is not necessary but may prove useful in the more refrac-
tory cases. In this case, a tapering dose schedule over a period of
7 days can be used.
Injections of local anesthetic and steroid into the cervical
epidural space may provide some pain relief. This again is based
on the premise that inflammation plays a significant role in the
production of radicular symptoms. This procedure, however,
requires considerable experience and technical competence and
carries with it a risk of complications. Some authors have had
limited success with this procedure, but we do not routinely use
cervical epidural steroids.
The prognosis for patients with an acute herniated cervical
disk is generally very good. If patients are compliant with the rest
and immobilization program as outlined, most are able to return
to work within a period of 1 month, at least under light duty
conditions. Indications for surgical intervention in the treatment
of an acute herniated disk include persistent radicular pain unre-
sponsive to at least 3 months of conservative therapy, progressive
neurologic deficit, static neurologic deficit in the presence
of radicular-type pain, and radiographic studies such as CT or
MRI with a myelogram confirmatory of clinical signs and
symptoms (Fig. 3d.5). Diskectomy for pain relief has been shown
to be greater than 90% effective when performed for the proper
diagnosis.
CERVICAL DEGENERATIVE DISK DISEASE
Cervical degenerative disk disease can produce cervical spondy-
losis in isolation or in concert with a number of syndromes,
including myelopathy, radiculopathy, myeloradiculopathy, and
associated visceral or vascular encroachment. Radiculopathy
secondary to spondylosis is not discussed separately because it
does not significantly differ from radiculopathy secondary to
acute herniated disk disease as previously described.
Spondylosis
The human cervical spine has a high degree of mobility and flex-
ibility. It has paid the price for this mobility with an almost
universal propensity for degenerative change. Cadaveric studies
have revealed that nearly everyone will demonstrate some degree
of degenerative change in the cervical spine by age 55. Cervical
spondylosis is a term used to describe the chronic process of
degenerative changes that occur as part of natural aging. These
include changes in the vertebral body, intervertebral disk, uncover-
tebral joints of Luschka, zygapophyseal joints, ligamentum
flavum, dura, and soft tissues.
The primary cause of cervical spondylosis appears to be age-
related changes that occur in the intervertebral disks, including
loss of annulus fibrosus elasticity, desiccation of the nucleus
pulposus, and narrowing of the disk space with or without asso-
ciated disk rupture. Narrowing of the disk space creates excessive
motion between vertebral segments, causing secondary changes
such as osteophyte formation, facet joint and ligamentum
flavum hypertrophy, inflammation of synovial joints, and pos-
sibly microfractures. Ultimately, spinal canal and lateral recess
stenosis may result. These changes are seen in varying degrees in
patients with spondylosis and to a lesser extent in asymptomatic
Chapter 3d Cervical degenerative disk disease 77
Table 3d.2 Neurology of the upper extremity
Disk Root Reflex Muscles Sensation
C4-C5 C5 Biceps reflex Deltoid Lateral arm
Biceps Axillary nerve
C5-C6 C6 Brachioradialis Wrist extension Lateral forearm
reflex Biceps Musculocutaneous
(biceps reflex) nerve
C6-C7 C7 Triceps reflex Wrist flexors Middle finger
Finger extensions
Triceps
C7-T1 C8 Finger flexion Medial forearm
Hand intrinsics Med. Ant. Brach.
Cutaneous nerve
T1-T2 T1 Hand intrinsics Medial arm
Med. Brach.
Cutaneous nerve
elderly individuals and can produce a variety of clinical signs and
symptoms depending on the severity. However, not everyone
has clinically symptomatic complaints. Friedenberg and Miller
4
showed a lack of correlation between symptoms and degenera-
tive changes seen on plain radiographs of the cervical spine.
These changes become clinically significant only when directly
related to symptoms.
Historically, the typical patient with cervical spondylosis is
over 40 years of age and has a complaint of neck ache. Referred
pain patterns discussed above include shoulder pain, suboccipital
referred pain, occipital headaches, intrascapular pain, anterior
chest wall pain, or other nonspecific symptoms such as blurred
vision and tinnitus.
Physical examination of a patient with cervical spondylosis
often reveals little in the way of objective clinical findings.
Neurologic findings are generally normal in isolated spondylosis
without radiculopathy or myelopathy. Some decrease in motion
of the cervical spine may be evident. Point palpation may reveal
some tenderness along the midline of the neck and in areas of
referred pain.
Plain radiographs are obtained primarily to rule out more
serious causes of neck pain. Plain films in the anteroposterior,
lateral, and oblique planes reveal varying degrees of change,
including disk space narrowing, osteophyte formation, foraminal
narrowing, facet degeneration, or instability patterns. Once again,
these changes do not directly correlate with the presence or
severity of clinical symptoms.
Treatment
The mainstay of therapy for patients with cervical spondylosis is
conservatism. In the presence of acute exacerbation of symptoms
against a background of chronic disease, rest and immobilization
are generally beneficial. Aspirin or other nonsteroidal antiinflam-
matory medications may be helpful also for an acute exacerba-
tion and may be needed on a chronic basis to abate symptoms.
As previously described, trigger point injections may be of
value also both diagnostically and therapeutically. A soft cervical
orthosis may assist in resting and immobilizing the cervical
spine. Cervical isometric exercises and changes in the patients
daily activities such as work habits, sleeping positions, and auto-
mobile driving may be useful adjuvant therapies in the treatment
of these chronic patients. In this patient population, the use of
manipulative techniques and traction protocols should not be
performed.
Spondylosis with myelopathy
When the previously described degenerative changes of the
cervical spine become so severe as to impinge on the spinal cord,
a pathologic process termed myelopathy is produced. Spinal cord
and nerve root compression produces myeloradiculopathy. Having
been described already in detail in relation to acute herniated
disk disease, radiculopathy is not addressed here.
Those patients with developmental cervical stenosis are
more prone to the development of spondylitic myelopathy at a
younger age. Etiologic factors in the reduction of canal reserve vol-
ume include hypertrophy of the ligamentum flavum, facets, lamina,
and dura with redundant annulus fibrosus; foraminal osteophyte
compression of radicular vessels; vertebral osteophyte cord com-
pression; tethering of the cord by dentate ligaments; and ossifica-
tion of the posterior longitudinal ligament or ligamentum flavum.
C5
JS
A B
Figure 3d.5 Magnetic resonance images of a 45-year-old man with unilateral C6 radiculopathy. (A) Midsagittal view showing more pathologic
anatomy than a parasagittal view of the unaffected side (arrows). (B) Parasagittal view of the affected side showing hard disk pathology (arrow).
(From Boden SD, Rothman RH, Wiesel SW, Laws ER, Boden SD: The aging spine: essentials of pathophysiology, diagnosis, and treatment.
A reduction in volume of the spinal canal can result in direct
canal compression and intrinsic or extrinsic ischemia. Edward
and LaRocca
3
demonstrated that development of myelopathy
with spondylosis is almost certain with canal diameters of less
than 10 mm. Patients with canals 10-13 mm in diameter are
at risk, and those with canals 13-17 mm are myelopathic
prone. Myelopathy rarely develops with canal diameters greater
than 17 mm.
In addition to these static considerations, dynamic changes
in the cervical spine may result in myelopathy. Penning and
van der Zwaag described the pincer mechanism in 1966. In this
mechanism, the spinal cord becomes compressed between the
anterosuperior margin of the lamina of the inferior vertebrae
and the posteroinferior osteophyte (i.e., hard disk disease) of the
superior level. Flexion of the spine causes stretching of the cord
over vertebral body osteophytes, with extension possibly result-
ing in retrolisthesis of one vertebral body on another or buckling
of the hypertrophied ligamentum flavum. All these dynamic
changes can cause compression of the cord as it passes through
the cervical canal.
Clinically, most patients are between 40 and 60 years of age
when initially seen, with males affected more often. Myelopathy
develops in fewer than 5% of patients with cervical spondylosis.
Although a history of trauma may occasionally be given, the
onset is more often insidious. Acute myelopathy generally reflects
a central soft disk herniation producing a high-grade block. The
natural history is one of deterioration initially, followed by a
plateau in deficit lasting for several months. The exact clinical
picture is variable, with a patchy distribution of deficits. This
distribution depends on the number of levels involved and the
severity of cord impingement at each level.
Typically, patients have a gradual onset of numbness and
paresthesias with associated weakness and clumsiness. Often, a
history of difficulty writing is elicited. Lower extremity symp-
toms may precede those in the upper extremity and include gait
disturbances, peculiar leg sensations, weakness, hyperreflexia,
spasticity, and clonus. Upper extremity findings that may initially
be unilateral often progress bilaterality. These include hyper-
reflexia, a brisk Hoffmann sign, and muscle atrophy, particularly
of the hand intrinsics. Abnormalities in micturition are seen
in approximately one third of cases and connote a more severe
cord impingement. Sensory changes are a less reliable sign of
myelopathy. Spinothalamic tract signs may be seen with distur-
bances in pain and temperature sensation in the upper extrem-
ities, thorax, or lumbar region. These may be characterized by
a stocking-glove distribution. Dorsal column function can be
affected with resultant vibratory and proprioceptive disturbances.
Impingement on the dorsal division of the nerve root may
produce unusual dermatomal sensory changes.
In the event of a severe myelopathy, one of several spinal
cord syndromes may develop. These include (1) Brown-Sequard
syndrome with ipsilateral motor dysfunction, contralateral pain,
and temperature dysfunction one to two levels below the motor
involvement; (2) central cord syndrome with upper extremity
involvement greater than lower extremity involvement; (3) trans-
verse lesion syndrome, which occurs most commonly with
involvement of the posterior columns, spinal thalamic tracts, and
corticospinal tracts; (4) brachialgia cord syndrome with upper
extremity radicular symptoms and long-tract signs; and (5) motor
system syndrome with corticospinal tract involvement and
weakness of both the upper and lower extremities.
The differential diagnosis for patients with cervical spondylitic
myelopathy includes such disorders as multiple sclerosis, amy-
otrophic lateral sclerosis, spinal cord tumors, syringomyelia, disk
herniation, intracranial lesions, low-pressure hydrocephalus, and
subacute combined degeneration. Each of these should be ruled
out with appropriate history, physical examination, and diagnostic
studies.
Plain radiography in these patients generally demonstrates
typical degenerative findings, including spinal canal narrowing by
prominent posterior osteophytes, variable foraminal narrowing,
disk space narrowing, facet joint arthrosis, and instability. MRI
can demonstrate structural and parenchymal changes (Fig. 3d.6).
The myelogram also is valuable in demonstrating the typical
washboard appearance (Fig. 3d.7) with multiple anterior and
posterior dye column defects. The posterior defects are produced
by facet joint arthrosis and ligamentum flavum buckling.
Treatment
Studies looking at the natural history of cervical spondylitic
myelopathy are inconsistent and often difficult to compare
because of the lack of a universal classification system. Some
common factors, however, can be identified. The age at onset
and duration of symptoms before the onset of treatment are
prognostic factors. Increased age at diagnosis and delay in treat-
ment for longer than 1 year indicates a poor prognosis. Most
patients in these series had periods without progression, or
plateau phases, interspersed with periods of rapid deterioration.
Some patients had a steady progression of the disease with
resultant severe disability. Conservative therapy rarely reverses
the myelopathy, although in a patient who is a poor surgical
candidate because of concomitant medical conditions, conserva-
tive measures such as immobilization and rest with a cervical
orthosis are viable options. In general, however, management of
patients with myelopathy requires surgical decompression of the
spinal canal and prevention of further spinal cord impingement
and vascular compromise. Progression of the myelopathy after
surgical decompression is uncommon. Both anterior and poste-
rior surgical procedures have been reported to lead to improve-
ment in the myelopathy of patients with cervical spondylosis.
RHEUMATOID ARTHRITIS
Approximately 2% to 3% of the general population is affected
with rheumatoid arthritis. Of these, 86% show radiographic
evidence of cervical spine disease, and 60% have clinical signs
and symptoms of cervical spine involvement reflecting the ero-
sive inflammatory changes characteristic of this systemic disease
process. The clinical variable that is the most consistent indicator
of cervical spine involvement is the presence of hand deformities.
11
Involvement of the cervical spine consists of three distinct
syndromes: atlantoaxial instability, basilar invagination, and
subaxial instability. Although atlantoaxial instability is the most
common of these syndromes, Ranawat et al
12
showed that they
tend to occur in combination. They found that 60% of patients
had atlantoaxial instability, 16% had basilar invagination, and
60% had subaxial instability. Risk factors for the development
Chapter 3d Rheumatoid arthritis 79
Figure 3d.6 (A) A sagittal 500-ms TR/17-ms TE image in a patient who sustained a cervical extension injury. Note the disruption of the anterior
longitudinal ligament at multiple levels (solid white arrows) and the traumatic disk herniations (open arrows). Pinching occurs at the C5-C6 level
(black arrows). (B) A parasagittal 500-ms TR/17-ms TE image shows anterior longitudinal ligamentous disruption (arrows) and prevertebral soft
tissue swelling. (C) The midline sagittal 2000-ms TR/30-ms TE 7-mm image demonstrates ligamentous disruption (white arrows), prevertebral
edema (e), and pinching at C5-C6 (black arrows). The canal compromise appears more serious on this 7-mm sagittal image, most likely because of
a partial volume effect from the lamina laterally. (D) A 2000-ms TR/60-ms TE midline sagittal image shows similar findings, again with prevertebral
edema (e), ligamentous disruption (white arrows), and some increase in signal intensity of the spinal cord at the site of compression (black
arrows). (E and F) 2000-ms TR/90- and 120-ms TE images with similar findings, although the increased signal intensity within the spinal cord
secondary to edema is more obvious on those more T2-weighted scans. The absence of any significant focal areas of decreased signal intensity
indicates a relative absence of intramedullary hemorrhage (contusion) and a more favorable prognosis. Despite the initially severe neurologic
deficit, this patient eventually recovered significant function. (From Modic MT, Masaryk TJ, Ross JS: Magnetic resonance imaging of the spine,
ed 2. St. Louis, 1994, Mosby Year Book.)
of atlantoaxial instability include prolonged systemic steroid
use, long disease duration, older age, and erosive peripheral joint
involvement.
Patients with cervical spine involvement secondary to
rheumatoid arthritis often have occipital neuralgia caused by
compression of the greater occipital branch of C2. This gives the
typical complaint of headaches when upright that is relieved by
recumbency. Range of motion may be limited, and crepitation
or sensations of frank instability may be present, in which case
Lhermittes sign may be elicited with motion. Neurologic changes
can be variable and are often difficult to interpret in rheumatoid
patients, who may have severe involvement of the upper and
lower extremities. Physical examination should be performed
very carefully to rule out upper motor neuron signs, such as
Chapter 3d Rheumatoid arthritis 81
D
C
B
A
S M
34
S M
45
12 mm
S M
389
S M
3
4
5
6
Figure 3d.7 (A) Lateral roentgenogram of a 43-year-old man with complaints of left shoulder pain, gait abnormality, and leg weakness. He had
mild spondylotic changes and a congenitally narrow cervical canal (12 mm). (B) Lateral myelogram showing significant extradural defects at C3-C4,
C4-C5, and C5-C6. (C) A computed tomography myelogram shows large uncovertebral spurs (arrows) plus soft disk material protruding at C3-C4.
(D) Severe spinal cord flattening at C4-C5 from the disk and an osteophytic ridge. (From White AH, Schofferman JA: Spine care, vol. 2. St. Louis,
1995, Mosby Year Book.)
hyperreflexia and spasticity, and the presence of abnormal
reflexes, such as the Babinski and Hoffmann signs. Brainstem
involvement by compression of the invaginated dens and/or
associated pannus can result in symptoms of vertebrobasilar
insufficiency. Other nonspecific findings may include the onset
of bowel or bladder incontinence or retention, development of
spasticity, and a change in ambulatory status.
Evaluation of patients with any of these clinical symptoms
should first begin with plain radiographs of the cervical spine.
Common findings include osteopenia, facet erosion, disk space
narrowing, and subluxation of the lower cervical spine (step
ladder). Clinical management and operative indications can be
defined by five radiographic measurements: (1) the anterior
atlantodens interval, (2) the posterior atlantodens interval,
(3) the McGregor line, (4) the Ranawat measurement, and (5) the
Redlund-Johnell measurement
10
(Fig. 3d.8). Basilar invagination
occurs with upward migration of the odontoid process into
the foramen magnum with resultant brainstem impingement.
Radiographic evaluation includes a measurement of the distance
from the tip of the odontoid to beyond the MacGregor line. This
is seen on the lateral view of the cervical spine and represents
a line drawn from the tip of the hard palate to the posterior
base of the foramen magnum. Normally, the dens should not
protrude more than 4.5 mm above this line. Protrusion more
than 8 mm in females or 9.7 mm in males may be an indication
for surgery. A CT may be helpful in determining radiographic
landmarks, which tend to become more diffuse in the rheuma-
toid patient. Subaxial subluxations are also evaluated on dynamic
flexion-extension views of the spine. Significant subluxation
is defined as translation of one vertebral body on another of
3.5 mm or more or disk space angulation of 11 degrees or more.
Treatment
Most of these patients can be managed conservatively despite
the fact that cervical spine involvement may develop in a signif-
icant number. The mainstay of nonoperative therapy is a hard
cervical orthosis (Philadelphia collar), which produces sympto-
matic relief without actually affecting the atlantoaxial interval.
Medical treatment of these patients plays a crucial role in
nonoperative management. Medications such as oral steroids,
methotrexate, leflunomide, and other disease-modifying
antirheumatic drugs are administered under the supervision of a
rheumatologist.
Prognostically, these patients tend to do very well with con-
servative measures, and only a small percentage die of medullary
compression from significant atlantoaxial disease. Atlantoaxial
disease gradually worsens with time, with only 2% to 14% of
patients exhibiting progressive neurologic symptoms. To sum-
marize, surgical intervention should be considered in the pres-
ence of (1) more than 3.5 mm of mobile subaxial subluxation
on flexion-extension views, (2) atlantoaxial subluxation greater
than 8 mm in the presence of spinal cord compression on
flexion-extension radiographs, or (3) cranial settling indicative of
basilar invagination in the presence of radiographic evidence
(MRI) of cord compression. Additionally, in the absence of
these findings, the presence of a progressive neurologic deficit
is a strong indication for surgical intervention.
HYPEREXTENSION INJURIES (WHIPLASH)
Most hyperextension injuries to the cervical spine result from
rear-end automobile accidents, which cause acceleration hyper-
extension injuries in the drivers of the struck cars. Falls and
sports injuries contribute to the remainder of the hyperextension
injuries. This injury has great economic considerations. The term
whiplash injury was introduced by H. E. Crowe in 1928, and since
that time it has become a major source of litigation potential.
The pathophysiology behind a hyperextension injury involves
the soft tissues of the neck region.
9
Usually, the driver of the struck
automobile is relaxed and unaware of the incipient collision.
When struck from behind, the automobile accelerates forward
acutely. If no headrest is present, the drivers head is thrown back
and the neck forced into hyperextension as the torso continues
onward with the automobile. The sternocleidomastoid, scalenes,
and longus coli muscles are extended beyond their elastic limit
and are severely stretched or torn. Tears of the longus coli
muscles may be associated with a concomitant tear of the sym-
pathetic trunk and result in Homer syndrome. Further hyperex-
tension may result in injury to the larynx or esophagus with
subsequent hoarseness or difficulty in swallowing, respectively.
Injury to the anterior longitudinal ligament may result in
hematoma formation with cervical radiculitis or injury to the
intervertebral disk. Furthermore, when the head is thrown back-
ward, the jaw generally lags behind, resulting in injury to
the temporomandibular joint as the jaw falls open. When the
head recoils forward, the skull may strike the drivers wheel or
windshield, resulting in a head injury.
AADI
Figure 3d.8 (A) Measurement of anterior
atlantodens interval and posterior atlantodens
interval. (B) The Ranawat method for
measurement of vertical setting. (C) The
Redlund-Johnell method for measurement of
vertical setting. (From Monsey RD: J Am Acad
Orthop Surg 5:240-248, 1997.)
Hyperextension injuries in elderly patients with preexisting
cervical spondylosis may acutely compress the spinal cord as
the already limited spinal reserve volume is overcome. This cord
compression can take the form of a frank paralysis or a central
cord syndrome.
Patients with a hyperextension injury are generally examined
12 to 24 hours after the initial traumatic event. It is at this point
that the patient starts to feel stiffness in the neck and pain at the
base of the neck made worse by motion. The pain becomes
progressively worse, and eventually the slightest head or neck
movement elicits severe pain. The anterior cervical musculature
may be tender to palpation, and the patient may have hoarse-
ness, dysphagia, or pain with chewing or opening the mouth.
Pain may radiate into both shoulders and arms and upward into
the base of the skull. Other pain patterns may include the ante-
rior of the chest, interscapular region, and vertex of the skull.
The potential for a closed-head injury even in the absence of
visible head trauma should not escape the examiner. Concussion
can occur secondary to mechanical deformation during the
acceleration-deceleration phase of the injury. This may result in
headache, photophobia, mild transient confusion, fatigue, tinni-
tus, or transient concentration abnormalities.
Physical examination must be complete from head to toe so
that other associated injuries are not overlooked. The potential
for a chance fracture of the lumbar spine exists if the patient
was wearing a lap seatbelt. The head should be examined for any
evidence of a closed-head injury. A unilateral dilated pupil may
suggest an injury to the sympathetic chain as it travels along the
longus coli muscles with resultant Horner syndrome. It may also
indicate significant intracranial pathology in a patient with an
altered level of consciousness. Temporomandibular joint tender-
ness should be assessed as well as suboccipital tenderness, which
may indicate that the head struck the top of the seat.
A careful and thorough neurologic examination should be
performed. Again, particular attention should be paid to elderly
patients, who may have baseline spinal stenosis secondary to
cervical spondylosis with resultant cord injury or central cord
syndrome. If any objective neurologic deficit is identified,
further diagnostic tests, including CT and/or MRI, are necessary.
CT is better at providing bone detail, whereas MRI is better at
demonstrating soft tissue disruption such as intervertebral disk
protrusion.
In most cases of hyperextension injury, only soft tissue
disruption occurs. Plain radiographs should be obtained, how-
ever, to rule out unsuspected facet dislocations, facet fractures,
odontoid fractures, or spinous process fractures. In most cases,
these films are normal or may show some straightening of the
cervical spine. As noted, other diagnostic studies such as a
head CT should be obtained as the history and physical findings
dictate.
Treatment
Treatment involves primarily rest and immobilization. Rest
consists of a soft cervical orthosis that assists in relieving muscle
spasms and prevents quick movements of the head. Collar wear
beyond 2 to 4 weeks should not be encouraged, because this
may result in weakening of the neck musculature and, in turn,
development of a long-term psychoneurosis. Strict bed rest may
be necessary for 3 to 5 days if the symptoms are severe. Heat in
the form of hot soaks or heating pads may be useful. Although
narcotics should be avoided, medical therapy in the form of non-
narcotic analgesics, nonsteroidal antiinflammatory medications,
and muscle relaxants is helpful. Activity should be restricted
according to symptom severity.
Characteristically, improvement should occur after 2 weeks
of treatment as outlined earlier. If improvement does not occur,
an additional 2 weeks of rest and immobilization should be
prescribed with the addition of home cervical traction. Low-
weight traction consisting of 7 to 10 pounds for 20 to 30 minutes
per day generally gives symptomatic improvement. Persistence of
symptoms past 4 weeks should alert the physician to search for
another etiology. If headaches persist, a CT of the head should be
obtained to rule out a closed-head injury. If arm or shoulder pain
persists, CT of the spine and/or EMG should be performed.
In general, symptoms should be resolving by 6 weeks, although
complete resolution may take as long as 1 year.
8
Persistence of
symptoms beyond 6 weeks of severity equal in intensity to that
in the initial period may alert the physician to secondary gain
from pending litigation, and compensation neurosis should be
suspected. Before assigning this diagnosis, the physician should
certainly rule out any significant pathology by a careful history,
physical examination, and appropriate diagnostic testing. The
physician should not, however, over-treat the patient and encour-
age a retreat into a life of incapacitating neck pain.
The point at which the patient is able to return to the work
force depends on both the severity of the hyperextension injury
and the type of work involved. Patients performing heavy man-
ual labor may require 3 to 4 weeks of treatment before returning
to work, whereas those in less demanding positions may be able
to return after only 2 weeks. Limitations on the work performed
should consist of no lifting of objects heavier than 50 pounds,
no bending, and no prolonged periods of stooping. These restric-
tions should remain in effect for the first 3 weeks that the patient
has returned to work.
Depending on the severity of the injury, the prognosis is
generally good for complete recovery. Occasionally, a 5% to 10%
disability rating is appropriate in an honest patient in whom
symptoms persist during hard manual labor.
CERVICAL SPINE TREATMENT ALGORITHM
The goal for patients with neck pain is to obtain an accurate
diagnosis and administer the correct therapy at the appropriate
time. The previously presented clinical entities have been organ-
ized into a standardized approach,
16
a graphic display of which
is presented in the form of an algorithm in Figure 3d.9. The algo-
rithm aids in establishing the proper diagnosis and guides in
the delivery of the proper treatment. A summary of treatments
categorized by pathology is listed in Table 3d.3.
The algorithm begins with evaluation of those patients seen
for neck pain with or without associated arm pain. Patients
with a history of trauma and associated fractures and/or disloca-
tions are excluded. The first task is a thorough medical history
and physical examination to rule out the presence of cervical
myelopathy, as discussed earlier.
Chapter 3d Cervical spine treatment algorithm 83
Figure 3d.9 Cervical spine algorithm. (From Wiesel SW, et al: Neck pain. Charlottesville, VA, 1988, The Michie Company.)
If a myelopathic process is confirmed, surgical intervention
should be considered in a timely fashion. The best results are
obtained with only one- to two-motor unit involvement and
relatively short duration of symptoms. Further studies, including
myelography or MRI, should be performed to define precisely
the neural compression. Adequate surgical decompression should
then be performed.
If cervical myelopathy is ruled out, most patients should then
be started on a course of conservative management. Regardless
of the etiology of the neck pain, all patients are treated equally
in this regard. Initially, this nonoperative management consists
primarily of immobilization and drug therapy. A well-fitted soft
cervical collar should be worn for 24 hours per day to prevent
awkward positioning and movements during sleep and while
awake. In addition, antiinflammatory medications, analgesics,
and muscle relaxants will improve patient comfort.
Most patients will symptomatically improve with this pro-
tocol within approximately 10 days and should then start to be
weaned over the next 2 to 3 weeks. Additionally, their level of
activity should be gradually increased, and they should start a
series of exercises aimed at strengthening the paravertebral mus-
culature. If the condition remains unimproved, patients should
continue full-time collar wear and pharmacologic management.
If no significant improvement in symptoms is seen after 3 to
4 weeks, a trigger point injection at the point of maximum ten-
derness should be considered. This is performed with a combi-
nation of 10 mg of corticosteroid and 3 to 5 ml of 1% lidocaine.
If this is likewise not successful at 4 to 5 weeks, a trial of home
cervical traction may be considered.
For patients with neck pain, a total period of 6 weeks of
conservative management should be pursued. Most patients
respond to this program and return within 2 months to their
previous life-styles. If, on the other hand, the symptoms fail to
resolve within 6 weeks of conservative therapy, the patients are
then divided into two groups depending on whether neck or arm
pain (brachialgia) is the predominant complaint.
For those patients whose main complaint is neck pain and
for whom conservative therapy for 6 weeks has failed, plain radi-
ographs, including flexion-extension films, should be obtained.
Several of these patients will have evidence of instability, the cri-
teria for which include horizontal translation of one vertebra
on another of 3.5 mm or an angular difference of 11 degrees
between adjacent vertebrae. Most of these patients do well with
nonoperative management consisting of education and bracing,
but those who do not may require segmental spinal fusion.
A second group of patients have changes characteristic of
degenerative disease. Radiographic findings include osteophyte
formation, loss of intervertebral disk height, narrowing of the
neural foramina, and zygapophyseal joint osteoarthritis. As pre-
viously mentioned, degeneration of the cervical spine may be a
normal part of the aging process. The difficulty arises in determin-
ing which of the degenerative changes are clinically significant.
The most significant change has been found to be narrowing of
the intervertebral disk height, particularly at C5-C6 and C6-C7.
Treatment of these patients consists primarily of antiinflamma-
tory agents, support braces, and trigger point injections. During
quiet periods, isometric exercises should be used. Reexamination
is necessary to monitor for the development of myelopathic
symptoms or signs.
Most patients who have normal plain films receive a prelim-
inary diagnosis of neck strain. After failure to improve with
conservative therapy, these patients should have a thorough
medical evaluation and a bone scan to rule out infection, neo-
plasia, or inflammatory arthritis as the etiology of the neck pain.
If this workup proves negative, they should then undergo psy-
chosocial evaluation and receive treatment, if appropriate, for
depression or substance dependence, both of which can frequently
be found in patients with neck pain. If the psychosocial findings
prove normal, the patient is considered to have a diagnosis
of chronic neck pain. Treatment therefore consists of thorough
education and support, detoxification from narcotics, and insti-
tution of an exercise program. Antidepressant agents may prove
to be useful, and frequent reevaluations are necessary to avoid
overlooking any serious pathologic process.
Other large groups of patients in this algorithm are those in
whom arm pain is the predominant symptom. The etiology of
this pain may be either direct pressure from a herniated disk or
inflammation about a nerve on hypertrophic bone (hard disk
disease). Other causes of extrinsic compression of the vascular
or nervous structures supplying the upper extremity, including
pathologic processes of the chest and/or shoulder region, may
imitate brachialgia also and must therefore be ruled out. A thor-
ough history and physical examination, including an Adson
test, shoulder examination, and Tinels test of the carpal, cubital,
and ulnar tunnels, should be performed, with additional appro-
priate studies possible, based on the results. If an Adson test is
positive, vascular studies and EMG should be performed to
evaluate causes of thoracic outlet syndrome. Compression of
the brachial plexus may occur secondary to vascular structures,
cervical ribs, muscular or fibrous bands, or neoplastic processes.
Additionally, an apical lung carcinoma can cause brachial plexus
compression with or without Horner syndrome from sympa-
thetic chain involvement (Pancoast tumor).
Chapter 3d Cervical spine treatment algorithm 85
Table 3d.3 Treatment options for cervical spine
pathology
Neck sprain Spondylosis Hyperextension/
whiplash
Rest Rest Rest
Soft orthosis Soft orthosis Soft orthosis
Activity modification Activity modification Moist heat
NSAIDs Isometric exercises Activity modification
Muscle relaxants NSAIDs Physical therapy
Trigger point injections Trigger point injections NSAIDs
Acute herniated Spondylosis with Rheumatoid arthritis
disk myclopathy
Rest Rest/immobilization Hard orthosis
Soft orthosis (nonoperative candidate) Steroids/DMARDs
NSAIDs
Oral steroids
Epidural injections

Diskectomy Surgical decompression Surgical fusion
DMARDS, disease modifying antirheumatic drugs, NSAIDs, nonsteroidal antiinflammatory
drugs.
If plain films of the chest and shoulder are negative and fail
to reveal a source of extrinsic compression, EMG studies should
be performed. If these indicate peripheral nerve compression,
surgical decompression at the site should be performed. In the
presence of radicular symptoms, a myelogram or MRI should
be performed, and if the results are consistent with the neu-
rologic deficit, history, and physical findings, surgical decom-
pression of the nerve root should be undertaken because
conservative treatment results in persistent symptoms.
This algorithm is applicable to all patients with nonspecific
neck or arm pain and provides a rational approach to the ther-
apeutic and diagnostic sequence of events. The goal of this
approach must always be to treat appropriately the etiology
of the pain while avoiding unnecessary tests and therapeutic
interventions and, most importantly, to minimize the chance of
overlooking other serious pathologic processes.
CONCLUSION
This chapter summarizes some of the major pathologic processes
that affect the cervical spine. A detailed description of the
anatomy and of the pathophysiology is provided to aid in the
understanding of these clinical entities. In addition, the clinical
workup of each disease process is discussed, covering the present-
ing signs and symptoms, corresponding physical examination,
and pertinent diagnostic studies. A special emphasis is placed on
the treatment of cervical spine disease, which is individualized
for each pathologic process. Finally, a treatment algorithm is
presented that provides a coherent clinical decision-making
process combined with a standardized approach to treatment of
cervical spine disease.
REFERENCES
1. Boden SD, McCowin PR, Davis DO, Dina TS, Mark AS, Wiesel S: Abnormal magnetic-
resonance scans of the cervical spine in asymptomatic subjects: a prospective
investigation. J Bone Joint Surg 72(8):1178-1184, 1990.
2. Dwyer A, Aprill C, Bogduk N: Cervical zygapophyseal joint pain patterns. I. A study in
normal volunteers. Spine 15:453-457, 1990.
3. Edward WC, LaRocca SH: The developmental segmental sagittal diameter in com-
bined cervical and lumbar spondylosis. Spine 10:43-49, 1985.
4. Friedenberg ZB, Miller WT: Degenerative disc disease of the cervical spine. J Bone
Joint Surg 45A:1171-1178, 1963.
5. Grubb SA, Kelly CK: Cervical discography: clinical implications of twelve years of
experience. Spine 25:1382-1389, 2000.
6. Henderson CM, Hennessy R, Shuey H: Posterolateral foraminotomy for an exclusive
operative technique for cervical radiculopathy: a review of 846 consecutively oper-
ated cases. J Neurosurg 13:504-512, 1983.
7. Kang JD, Stefanovic-Racic M, Mcintyre LA, Georgescu HI, Evans CH: Toward a biochemi-
cal understanding of human intervertebral disc degeneration and herniation: contri-
butions of nitric oxide, interleukins, prostaglandin E2 and matrix-metallo-proteinases.
Spine 22:1065-1073, 1997.
8. McNab I: Acceleration injuries of the cervical spine. J Bone Joint Surg 46A:1797-1799,
1964.
9. McNab I: The whiplash syndrome. Orthop Clin North Am 2:289-403, 1971.
10. Monsey RD: Rheumatoid arthritis of the cervical spine. J Am Acad Orthop Surg
5:240-248, 1997.
11. Oda T, Fujiwara K, Yonenobu K, Azuma B, Ochi T: Natural course of cervical spine
lesions in rheumatoid arthritis. Spine 20:1128-1135, 1995.
12. Ranawat CS, OLeary P, Pellici P, Tsairis P, Marchisello P, Dorr L: Cervical spine fusion
in rheumatoid arthritis. J Bone Joint Surg 61A:1003-1010, 1979.
13. Rothman RH, Marvel JP: The acute cervical disc. Clin Orthop 109:59-68, 1975.
14. Rothman RH, Marvel JP: The spine, ed 4. Philadelphia, 1999, WB Saunders.
15. Stookey B: Compression of spinal cord and nerve roots by herniation of nucleus
pulposus in the cervical region. Arch Surg 40:417-432, 1940.
16. Wiesel S: Neck pain, ed 2. Charlottesville, VA, 1992, The Michie Company.
postures and forces (Fig. 3e.3). These elements should be recorded
along with their duration, frequency, and cause. For example, in
the claims processor job described in Table 3e.1, extreme reaches
to the workers side are required 80 times per day to get unfini-
shed files and 80 times per day to put aside finished files.
Workers must reach over the files and rotate their forearms to use
the keyboard 6 hours per shift. In the assembler job described in
Table 3e.2, the workers must reach for parts beside and behind
them 2400 times per 8-hour shift; they must elevate their elbow
above shoulder height and rotate their forearm 14,400 times per
shift, and so forth.
The analysis should also include an inspection of infrequent
or irregular elements. For example, in the claims processor job
(Table 3e.1), 3 of 10 claims are set aside to await additional infor-
mation that must be retrieved by telephone. In the assembler job
(Table 3e.2), 1 of 12 screws is defective and requires additional
movements and time to replace. By their very nature, it may be
hard to identify irregular elements from existing job descriptions
or observations. Often they are identified via worker and super-
visor interviews.
SPECIFICATION OF ADAPTATIONS
The causes of the physical stressors should be apparent from the
work evaluation. The tabulation of stressors and their causes
illustrated in Tables 3e.1 and 3e.2 provide a systematic format
for developing possible adaptations. This format also provides
insight into how the overall stressfulness of the job is affected by
the proposed control measures and how one adaptation may
affect other stressors. For example, in Table 3e.1 it can be seen
that the claims processors are exposed to 2 hours of a stressful
shoulder-neck posture per day to hold the phone handset. It can
also be seen that a headset or a bracket attached to the handset
could reduce this exposure. Yet another adaptation might be
passing uncompleted files to another worker who does all the
phoning; however, this solution could result in increased key-
board times and other undesirable effects.
Reaching for documents is associated with cart location and
design. It follows that locating the carts close to the workers
side and modifying them with a fold-down side would reduce
reaching. Because these reaches occur an average of only once
every 3 minutes, it can be argued that this work element is by
itself unlikely to produce adverse health effects; however, it can
also be argued that when combined with other factors, this
reaching could result in an adverse effect or could aggravate an
existing case. An analysis of the low cost associated with park-
ing the carts close to the workers versus the possible cost of
medical treatment and lost work for disabled workers would
support locating carts close to the workers. Such an analysis
would probably also support a modification of the cart with
drop sides.
Workplace adaptations may involve modification of
Work processes;
Work standards;
Design of methods;
Workplace layout;
Equipment;
Training.
Workplace Adaptation
Thomas J. Armstrong
The deviation of neck, shoulder, and elbow postures from neutral
positions is associated with adverse health effects such as fatigue
and chronic muscle, tendon, and nerve disorders. The effects of
these disorders range from minor discomfort and degraded
performance to disability. Available data suggest that the time at
onset of adverse effects decreases with increasing exertion dura-
tion, frequency, and force. This does not mean, however, that
some postures can or should be maintained indefinitely without
interruption. Also, it does not mean that brief exposures to extreme
postures are not desirable.
The relationship between certain work activities and adverse
health effects is referred to as the dose-response relationship
(see Chapter 1). The dose-response relationship provides insight
into how work can be designed to minimize the risk of possible
adverse health effects or to facilitate the return to work of persons
in whom an adverse effect may have developed. Unfortunately,
sufficient data are not yet available to specify job designs that
provide a specific level of risk. For example, it cannot be said
how many times a group of workers can exert a horizontal force
of 50 N to engage the bit of a powered screwdriver weighing 15 N
at an elevation of 1.5 m before unacceptable health effects would
develop in a given fraction of them. It is extremely important
that the work equipment and procedures be evaluated at all stages
of design and implementation.
Workplace adaptation entails three basic steps
14
:
1. Evaluation of the proposed or existing job;
2. Specification of adaptations;
3. Evaluation of adaptations.
It may be necessary to repeat one or more of these steps one
or more times to achieve a desired level of control.
EVALUATION
Evaluation entails documentation of the process, equipment, pro-
cedures, and environment and assessment of stressors, including
posture, force, duration, and frequency.
1,7
The documentation is
performed from available job descriptions, time studies, workplace
inspections and measurements, equipment specifications, and
interviews with workers and supervisors. This information is then
used to identify stressful postures and forces necessary to reach,
hold, and use work objects and the duration and frequency of
these exertions. Tables 3e.1 and 3e.2 and Figures 3e.1 and 3e.2
illustrate evaluation summaries of two jobs: claims processor and
assembler.
An assessment of stressful postures and forces entails examining
each step of the operation for extreme neck, shoulder, and elbow
C HA P T E R
3e
Work processes refer to the technologies used for completing
the work objectives. In the claims processor example (Table 3e.1),
the technologies are keyboards and telephones. Alternative tech-
nologies include scanners and electronic mail. In the assembler
example (Table 3e.2), the technologies include threaded fasteners;
alternative technologies include clips and adhesives.
Work standards refer to the quantity and quality of work pro-
duced in a given time. In the claims processor example, the stan-
dard is 80 claims per 8-hour shift; in the assembler example, the
standard is 2400 motor assemblies per 8-hour shift. The work
standard is an important factor in how many times per day workers
must assume a given posture or exert a given force. Reducing
work standards is generally considered an adaptation of last resort;
however, it may be shown that the lost productivity is more than
offset by the reduced cost of medical treatment and lost work for
a disabled worker.
Work methods refer to the procedures or sequence of move-
ments used to perform the job. In the assembler example, the
method entails getting motors from a bin, placing them on the
line, and driving six screws. A methods change to reduce reaching
would be to unload one corner of the bin and then rotate it
90 degrees so that the workers are always working from the
corner closest to them. A methods change may also require an
equipment change and worker training.
Workplace layout refers to the position of equipment and work
objects in the workplace. In the claims processor example, the
workplace layout includes the position in space of the carts with
files, the keyboard, the monitor, the phone, and the active file
with respect to the worker. Adaptations include repositioning the
carts to reduce reaching, adding equipment to allow repositioning
of the keyboard, and supplying adjustable document and monitor
holders. In the assembly example, adaptations include equipment
to reposition the parts bin and adjustment of the suspender so
that the tool can be positioned to minimize reaching.
Anthropometric data may be used to estimate reach distances.
3,11
Average link length proportions can be used with population stature
data to estimate vertical, horizontal, and lateral reach limits
(Fig. 3e.4). Caution should be used in interpreting reach predic-
tions based on link length data. A reach distance based on average
proportions and a given percentile stature may correspond to a
different percentile reach. Work locations should be made as
adjustable as possible to accommodate individuals and should
be tested with user trials.
8,12,14
Reach data for U.S. civilian popu-
lations are available from U.S. National Health surveys.
13
Chapter 3e Workplace adaptation 88
Table 3e.1 Sample documentation and analysis of claims processor job for identifying and
controlling shoulder and neck stressors
TITLE
Claims processor
STANDARD
Complete 80 claims per day
EQUIPMENT
Computer, keyboard, 13-inch color monitor and claim processor software
Desk
Staple remover
Stapler
Telephone with handset
Adjustable-height chair
Carts for holding files
METHOD
1. Get file from cartplace on lap in front of keyboard
2. Remove staples
3. Sort documents
4. Perform keystrokes to open file
5. Perform keystrokes to update file
6. Call for information as necessary3 calls per 10 claims
7. Perform keystrokes to close file
8. Staple documents
9. Stamp and date file
10. Place finished file in cart
11. Note: occasionally claims processor cannot finish file and will set it
aside at the front of desk until someone calls back with necessary
information
MATERIALS
Files weighing 5-50 N
ENVIRONMENT
Inside overhead fluorescent lights with diffusers
WORKER
Skilled male and female keyboard operators
Fifth percentile female to 95th percentile male stature
ERGONOMIC STRESSORS
Stressor
POSTURE
Reaching for unfinished files (80 times per shift)
Reaching over file on lap to use keyboard (6 hr/shift)
Looking down at file (4 hr/shift)
Extending the neck to see monitor through bifocals (2 hr/shift)
Reaching to put aside finished files (80 times per shift)
Inward forearm rotation and wrist deviation to position hands over keyboard
(6 hr/shift)
Holding phone between neck and shoulder (2 hr/shift)
Proposed Adaptation
Provide access for carts so that it can be positioned to minimize reaching
Provide adjustable tray to hold file above keyboard
Provide corrective lenses that do not require worker to extend neck
Investigate variable geometry keyboard to reduce forearm rotation
Provide headset for phone
Investigate adjustable keyboard holder
Investigate wrist rest
Provide adjustable monitor holder
Stressor
FORCE
Lifting files weighing up to 50 N from cart to lap (80 times per shift)
and from lap to cart (80 times/shift)
Proposed Adaptation
Provide access for cart so that it can be positioned to minimize reaching
Investigate drop side for cart
Equipment refers to hardware such as tools to drive fasteners or
shape and smooth surfaces, containers, jigs, fixtures for holding
parts, and seating to support the worker. A proposed adaptation
in the claims processor example includes modification of the cart;
adjustable holders for the keyboard, monitor, and files; and a
headset for the phone. In the assembly example, equipment
changes include an in-line screwdriver with articulating arm, an
indexing assembly line, and a turntable for the parts bin.
Training entails instructing workers on the hows and whys of
arranging and performing their work. In the claims processor
example, it should be explained to the workers where they should
position the carts and why this is necessary to prevent possible
shoulder problems. Follow-up training and evaluations should
be performed to determine whether the workers understand and
follow the specified procedures. If procedures are not followed,
further evaluations should be performed to determine why they
are not followed.
The design of adaptations should draw on all available
resources. Available resources vary from one situation to another,
depending on the size and type of industry. Possible resources
include
Job designers, such as engineers, facilities people, and setup

people;
Safety and health personnel, such as doctors, nurses, industrial

hygienists, and safety personnel;
Supervisors;
Workers or work representatives;
Purchasing;
Sales and technical representatives from suppliers;
Catalogs, brochures, and technical specifications;
Scientific papers, books, and magazines.

In general, the team approach is the most effective way to mobi-
lize the resources necessary to develop and implement workplace
adaptations. On occasion, however, the problems are conspicu-
ous and the solution is clear so organizing a special team is not
merited.
Development of adaptation is not an exact process.
Consequently, all adaptations should be evaluated to ascertain
their effectiveness.
EVALUATION OF ADAPTATIONS
Ideally, adaptations should be evaluated in terms of their effects
on upper limb disorders. Unfortunately, such evaluations are dif-
ficult. Upper limb disorders develop over long periods of time.
To determine the effect of a given adaptation on the occurrence
of disorders would require identification of a group of several
hundred workers, implementation of the adaptation in a random
subset of these people, and some kind of comparison adaptation
in the others.
6
The population would then have to be tracked for
Chapter 3e Evaluation of adaptations 89
Table 3e.2 Sample documentation and analysis of assembler job for identifying and controlling shoulder
and neck stressors
TITLE
Assembler
STANDARD
Assemble 2400 motor assemblies per 8-hour shift
EQUIPMENT
Assembly line (1 m above floor level)
Power screwdriver suspended above line
Rack and bin for holding parts
METHOD
1. Get motor assembly from bin (weight, 40 N) and position on
subassembly
2. Get handful of screws with one hand
3. Get screwdriver with other hand
4. Position screw in screwdriver 6
5. Drive screw (1 of 12 screws is defective and must be backed out
and replaced)
ENVIRONMENT
Inside overhead fluorescent lights with diffusers
WORKER
Males and females
Fifth percentile female to 95th percentile male stature
ERGONOMIC STRESSORS
Stressor
POSTURE
Reaching for motor assemblies located to side and behind worker
(300 times/hr)
Reaching for parts located to side and behind worker (300 times/hr)
Reaching for screwdriver located overhead (300 times/hr)
Driving 1800 screws/hr with pistol-shaped driver requires elevation of elbow
and forearm rotation
Reaching upstream and downstream to keep up with production line
(50% of time, but 90% of time when bad screws are encountered)
Proposed Adaptation
Position trays close to worker and production line to minimize reaching
Unload trays one corner at a time and then rotate tray 90 degrees to
minimize reaching
Adjust tool suspender to minimize tension and locate tool as close as possible
to point of use
Investigate use of in-line tool with articulating arm to control torque
Investigate indexing production line in which work object stops until released
by worker
Position work object as close to edge of production line as possible to
minimize reaching
Investigate quality control program to avoid defective screws that take extra
motions to try and to reject
Stressor
FORCE
Lifting motor assemblies weighing 40 N from bin (300 times/hr)
Pulling down power tool into work position (300 times/hr)
Proposed Adaptation
Investigate small hoist or air balancers to facilitate transferring motors
to line (See above recommendations for tool suspender)
1 or more years. Unfortunately, such studies are extremely difficult
and expensive. It is difficult to find large groups in which adap-
tations can be randomly assigned. Work activities are generally
dictated by production schedules that may cause the work popu-
lation to shrink or swell. In addition, nonhealth-related factors
may cause a turnover in the work population. Although evalua-
tion of health patterns is an important means of identifying
workers and jobs that merit further evaluation and assessing an
overall program, in most cases it provides only limited feedback
about specific adaptations.
Adaptations can be evaluated by using the same methods that
were used for the initial job evaluations. This analysis should
begin as the adaptations are developed on paper and continue
through the prototype, pilot testing, and implementation phases.
8
In some cases it may be possible to identify and evaluate other
jobs at that work site or other work sites where the proposed
adaptations have already been implemented. In other cases it
may be necessary to develop prototypes and conduct pilot testing
on a small number of the proposed interventions. Worker feedback
can be obtained through interviews; however, care should be
taken to avoid leading questions.
9
The questions should be struc-
tured in such a way as to provide guidance on how to enhance
the adaptation. For example, one of the proposed adaptations
for the assembly job was the use of another tool and locating it
to minimize reaching. In this case, workers could be permitted to
try several tools and then rank them in order of preference. They
could also be asked to try the tools at several locations and rate
them on a scale of 0 to 10 where 0 is too low, 5 is just right,
and 10 is too high.
2,12
Even though these measures do not
ensure that future shoulder, neck, or elbow problems will not
develop, they do provide a basis for selecting a work configuration
that minimizes stress on the worker.
a
b
c
d
e
f
C
B A
Figure 3e.1 (A) Illustration of a claims processor job. (B) Major
stresses include reaching for documents, holding the telephone,
reaching for the keyboard, looking down at documents, and reaching
to get and put aside documents. (C) Possible claims processor job
interventions include an adjustable document holder (a), adjustable
monitor holder (b), adjustable keyboard holder (c), drop-side cart (d),
headset for phone (e), and optically correct glasses (f).
Chapter 3e Evaluation of adaptations 91
0" 12" 24" 36"
Shoulder
Elbow
90
60
A
0" 12" 24" 36"
Shoulder
Elbow
90
60
B
Figure 3e.2 (A) Work station layout for an assembler.
(B) Proposed interventions for the assembler example
include using a narrower conveyor to reduce reaching over
line dead space, using an indexing line so that the worker
does not have to chase the assemblies, and using a
smaller box of parts mounted on a turntable to reduce
reaching to the side and behind the worker.
Discomfort patterns can also be used to evaluate work designs
before and after they are implemented.
4,5,10
Workers are shown
pictures of the body and asked to identify and rate areas of
discomfort. Discomfort patterns provide information about many
parts of the body, as well as those parts likely to be affected by the
stress of concern and the proposed adaptation. Often, the variation
from within and between workers is considerable, and rigorous
statistical conclusions may not be possible.
SUMMARY
The available data are not yet sufficient to develop design speci-
fications that can be used to achieve a given level of risk of neck,
shoulder, and elbow disorders; however, the data do provide
insight into some of the things that can be done to reduce risk.
Control of disorders entails three basic steps: (1) evaluation of
Extreme elbow flexion Outward forearm rotation Inward forearm rotation
Elevated elbow Reaching behind the back
Neck deviation Neck flexion or extension
Figure 3e.3 Shoulder and neck stressors include extreme neck, shoulder, and elbow postures and force. (Modified from Armstrong TJ: Hand Clin
553-565, 1986.)
0.186
0.129
0.146
0.108
1.000
A B
0.818
0.630
Occasional
reach
Frequent
reach
Figure 3e.4 (A) Average link length proportions can be
used with population stature data to estimate vertical,
horizontal, and lateral reach limits. (B) The outer arc
represents maximum reach without bending. The inner arc
represents maximum reach without bending and not flexing
the shoulder more than 30 degrees to minimize loads on
shoulder tissues.
the job to determine the frequency, duration, and cause of
extreme reaches and forces; (2) specification of adaptations; and
(3) evaluation of the adaptations. It may be necessary to repeat
these steps before the desired level of control is achieved.
Development of workplace adaptations should be integrated into
an ongoing program that includes health surveillance, job surveys,
evaluation of affected workers and jobs, medical management,
training, and a team approach with participation from all levels
of the organization.
REFERENCES
1. Armstrong TJ: Ergonomics and cumulative trauma disorders. Hand Clin 2(3):553-565,
1986.
2. Armstrong TJ, Punnett L, Ketner P: Subjective worker assessments of hand tools used
in automobile assembly. Am Ind Hyg Assoc J 51(12):639-645, 1989.
3. Armstrong TJ, et al: Repetitive trauma disorders: job evaluation and design. Hum
Factors 28(3):325-336, 1986.
4. Corlett EN, Bishop RP: The ergonomics of spot welders. Appl Ergonom Mar:23-31, 1978.
5. Harms-Ringdahl K: On assessment of shoulder exercise and load-elicited pain in the
cervical spine. Biomechanical analysis of load-EMG-methodological studies of pain
provoked by extreme position. Scand J Rehab Med Suppl 14:1-40, 1986.
6. Hennekens CH, Buring JE, Mayrent SL, eds: Epidemiology in medicine. Boston, 1987,
Little, Brown.
7. Keyserling WM, Armstrong TJ, Punnett L: Ergonomic job analysis: a structured approach
for identifying risk factors associated with overexertion injuries and disorders.
Appl Occup Environ Hyg 6(5):353-363, 1991.
8. McClelland I: Product assessment and user trials. In JR Wilson, EN Corlett, eds:
Evaluation of human work: a practical ergonomics methodology. New York, 1990,
Taylor & Francis, pp. 218-247.
9. McCormick E: Job and task analysis. In G Salvendy, ed: Handbook of industrial
engineering. New York, 1982, John Wiley & Sons, pp. 2.4.1-2.4.21.
10. Saldana N, et al: A computerized method for assessment of musculoskeletal discomfort
in the workforce: a tool for surveillance. Ergonomics 37(6):1097-1112, 1994.
11. Ulin SS, Armstrong TJ, Radwin RG: Use of computer aided drafting for analysis and
control of posture in manual work. Appl Ergonom 21(2):143-151, 1990.
12. Ulin SS, et al: Effect of tool shape and work location on perceived exertion for work
on horizontal surfaces. Am Ind Hyg Assoc J 54(7):383-391, 1993.
13. U.S. Department of Health, Education and Welfare: Weight and height of adults
18-74 years of age: United States, 1971-1974. Vital Health Stat 11(211),
Hyattsville, MD, 1979, National Center for Health Statistics.
14. Wilson JR: A framework and a context for ergonomics methodology. In JR Wilson,
EN Corlett, eds: Evaluation of human work: a practical ergonomics methodology.
London, 1990, Taylor & Francis, p. 6.
Chapter 3e References 93
C HA P T E R
Lower Back
4
include defining and quantifying the pain experience and con-
trolling the effects of individual and cultural factors on pain per-
ception and interpretation. Studies can be complicated also by
uncertain reliability in a persons recall of symptoms and by vari-
ations in how researchers define their presence.
83
Back pain problems, moreover, are identified through numer-
ous different reporting systems, primarily health surveys and
symptom complaints noted in clinical or workplace settings.
In North America, for example, in contrast to some other indus-
trialized countries, pain in the workplace becomes known or regi-
stered through the filing of an incident report or workers
compensation claim, and back pain is labeled a back injury.
Taylor
91
described a complex chain of events that leads to the
production of industrial insurance and sickness data and makes
it clear that the occurrence of back pain incidents registered in
the industrial setting cannot be equated to the occurrence of
morbidity. Failure to distinguish between studies of different
back-related outcomes such as spine pathology, back symptom
complaints, industrial injury claims, absenteeism, and long-term
disability may lead to misleading generalizations and inaccurate
conclusions.
Along with different low back pain problem case definitions
themselves are the influences and potential biases of the systems
through which they are registered. An example of the potentially
large effect of health system differences has been provided by
Cherkin et al,
23
who compared rates of back surgery in 11 devel-
oped countries and examined the association between these rates
and the number of neurologic and orthopedic surgeons per capita.
They found that the rate of back surgery was at least 40% greater
in the United States than in any of the other countries investigated
and more than four to five times that of England and Scotland.
They also found that the rate of back surgery was positively corre-
lated with the number of surgeons per capita (Fig. 4a.1).
Assessment of occupational and other
relevant exposures
In addition to the challenges posed by definitions, influences,
and biases involved in back pain are the methodologic chal-
lenges of measuring occupational and other relevant exposures.
Occupational exposures that appear frequently on lists of sus-
pected risk factors are vehicular vibration and physical loading
involving heavy lifting, bending, twisting, and sustained nonneu-
tral postures. Virtually all inhabitants of developed countries are
exposed to these factors during leisure time and work. Exposure
is therefore a matter of degree and requires reliable valid methods
of measurement. Unfortunately, practical tools to identify
and quantify the different exposures in epidemiologic studies of
large populations are not fully developed. Further complicating
measurement is that for many outcomes such as structural changes
of the spine, data are needed on lifetime loading rather than sim-
ply on current conditions.
Most studies have used the job title as an indicator of occu-
pational loading. This simple method of estimating occupational
exposure can be highly inaccurate. The activities and environ-
ments of persons with similar job titles can vary substantially,
and the loading profiles of workers who remain in one occupa-
tion for many years can change greatly. Moreover, most persons
Epidemiology: Incidence,
Prevalence, and Risk
Factors
Michele Crites Batti, Tapio Videman, and Douglas Gross
The high prevalence and social and economic impact of low back
pain and related disability are well recognized. Low back pain is
one of four musculoskeletal conditions specifically targeted by
the Bone and Joint Decade (2000-2010) initiative endorsed by the
World Health Organization.
15,106
Related to the workplace, back
injury claims comprise the most expensive category of industrial
injuries
40,65
and are one of the most common causes of disability
in adults under 45 years of age.
24,90
In response to this problem,
many workplace programs and medical services have been
designed to prevent back problems or to minimize their negative
consequences. Limited progress has been made, however, in alle-
viating this common condition and its consequences.
When the underlying condition and risk factors for an ailment
are understood, prevention and treatment strategies can be ration-
ally based and well directed. In such situations, interventions are
likely to be successful. Unfortunately, medical science still lacks
information sufficient to guide the prevention and treatment of
common back pain. Epidemiologic studies have sought to gain
information that could be helpful in guiding these efforts.
Epidemiology generally refers to the study of occurrence rates
of diseases and especially factors associated with disease occur-
rence or nonoccurrence. A primary goal of such studies is to
obtain information about the disease cause. However, challenges
of the most basic nature have hindered epidemiologic studies of
back problems.
CHALLENGES FACING EPIDEMIOLOGIC
STUDIES OF BACK PAIN PROBLEMS
Definition of the problem
A central challenge of epidemiologic studies of back pain prob-
lems is that in the vast majority of cases the underlying pathology
or condition is unknown.
29,89
Current clinical examination meth-
ods rarely identify the underlying pathology of either acute or
recurrent back pain in the absence of major trauma. Despite this
reality, there is a tendency to approach back pain as though
it were a specific disease or injury state. Miettinen and Caro
67
cautioned that epidemiologic studies based solely on a com-
plaint have limited value and that inferences to pathology can be
misleading. A complaint is a voluntary behavior and as such can be
influenced by a variety of factors other than physical pathology.
Further problems encountered in studying any type of pain
C HA P T E R
4a
hold several different types of jobs during their working years,
and their current positions may poorly reflect the physical load-
ing experienced over their working lives. It has also been shown
that workers in sedentary jobs tend to engage in more physically
loading leisure-time activities than do workers with physically
heavy jobs, which can confound attempts to investigate the effects
of occupational loading.
50
Conceptually, studies designed with
the aim of understanding the effects of physical loading on back
pain problems should be assessing total loading exposures both
within and outside the work environment. Such studies are very
seldom performed.
Identifying factors associated with risk can give clues about
causation, but an understanding of the basis for associations is
required to formulate optimal prevention strategies. Leino
58
showed that greater exercise activity was associated with fewer
back symptom reports and back findings, for example, and
Videman et al
95
found that former elite athletes had significantly
fewer back pain complaints than did nonathletes. If exercise has
a protective effect and decreases the risk of back symptoms or
spine pathology, then exercise participation could be expected to
help prevent back pain. Exercise is also a marker for other healthy
life-style behaviors, as well as higher education, higher life satis-
faction, and lower occupational physical demands and psychoso-
cial problems,
85
all of which can affect back pain reporting. Because
physical loading from certain forms of exercise and sports can
increase spine pathology, exercise itself may not be directly benefi-
cial and may even have some harmful effects on the spine, so that
the apparent benefits are produced instead by factors not associ-
ated with exercise. If this were the case and exercise were only a risk
indicator, exercise without other changes in life-style would be
unlikely to decrease back troubles. Before interventions are
planned, it would be important to sort out whether exercise is a
beneficial factor or only an indicator of healthier life conditions.
An odd paradox exists in perceptions of the effects of physical
loading at work and at leisure. Physical loading associated with
work and with leisure or sport activity share many dimensions
such as frequency, intensity, and duration, yet adaptation to
loading, which is an expected result of regular exercise, receives
little attention in studies of occupational loading. It is often
stated that one reason for disability is that work demands exceed
the capacity of the worker. The level of physical demands over
prior months, however, is a primary determinant of individual
capacity, which should include an adaptation of strength to rou-
tine daily work demands, as is the case with exercise training.
Yet perhaps the greatest challenge in studies of the association
between workplace exposures and back pain incidents and
injury claims in the developed countries of the world is the
injury model commonly used to explain the presence of back
pain. Under the injury model, occupational physical loading
exposures are believed to be primarily responsible for damage to
the back and related pain. This belief naturally leads to greater
attribution of symptoms to occupational exposures as workers
search for possible causes of their problem. Attributing back pain
to work activities may be further enhanced within a workers
compensation system that offers clear benefits to causation lying
with work. These inherent problems to studying back pain report-
ing in the workplace and its association with work activities
greatly complicate, and in some cases may invalidate, study find-
ings and their interpretation.
Causation versus exacerbation
Another unresolved issue is that of back pain causation versus
exacerbation. Certain occupational exposures, like heavy materi-
als handling in bent and twisted postures, awkward sustained
postures, or other forms of physical loading, play a role in the
conditions underlying back symptoms that is not well under-
stood. Whether physical loading contributes to the pathology
underlying common back pain or simply exacerbates symptoms
from an already present underlying condition is a matter of
current controversy.
Chapter 4a Epidemiology: incidence, prevalence, and risk factors 98
1.2
1
0.8
0.6
0.4
0.2
0
0 10 20 30 40 50 60 70 80 90 100 110
B
a
c
k

s
u
r
g
e
r
y

r
a
t
e
(
a
s

c
o
m
p
a
r
e
d

t
o

t
h
e

U
n
i
t
e
d

S
t
a
t
e
s
)
Netherlands
United States
Denmark
Finland
Ontario Norway
South Australia
New Zealand
Manitoba
England
Scotland
Sweden
Number of orthopaedic surgeons and neurosurgeons (per million people)
Figure 4a.1 Relationship between the relative supply of orthopedic surgeons and neurosurgeons in a country and the countrys back surgery
rate. (From Cherkin DC, Deyo RA, Loeser JD, Bush T, Waddell G: Spine 19:1201-1206, 1994.)
Some evidence suggests that routine physical loading expo-
sures, such as seen in occupations with heavy physical demands,
may have a modest role in influencing underlying pathology and
a role in exacerbating such pathology. Videman et al
99
controlled
for spine pathology and found that a history of back symptoms
was correlated with physical loading. This finding supports the
belief that loading exacerbates symptoms from existing condi-
tions. The same study found that annular tears were more com-
monly found in subjects who engaged in occupations involving
heavy physical loading, which suggests that it can lead also to
increased risk of some structural failures. The role of occupa-
tional loading in degenerative changes and pathology, however,
appears to be considerably less than previously thought.
INCIDENCE AND PREVALENCE
As mentioned previously, there are no standard definitions for
determining the presence or absence of back pain problems in
the general population; instead, various definitions and methods
for collecting such data are used. This leads to wide variations in
prevalence and incidence estimates. A systematic review of the
scientific literature from 1966 to 1998 presenting data on the
prevalence of low back pain yielded point prevalence estimates
from 12% to 33%, 1-year prevalence estimates from 22% to 65%,
and lifetime prevalence estimates from 11% to 84%.
102
Another
review of the literature on low back pain prevalence estimated
the point prevalence specifically in North America at 5.6%, but
similarly broad ranges were noted in prevalence estimates as in
the aforementioned review.
63
These wide ranges are influenced by many factors, not the
least of which is the definition of low back pain used in terms of
pain severity, duration, and associated disability. Responses to
such questions as Have you ever had low back pain? result in
high estimates, whereas low back pain that is defined as pro-
longed or disabling yield estimates toward the lower end of the
range. What is clear is that back pain problems are ubiquitous in
the general adult population. Work-related low back pain must be
viewed against this high baseline. Whether or not a back injury
has occurred at the workplace, back pain among workers is com-
mon, and many believe that their work is to blame. This is a
natural and expected consequence of beliefs fostered by the
injury model that back pain problems are the result of structural
damage caused by physical demands.
Further complicating the determination of occurrence rates is
the recognition that back pain cannot be neatly categorized as
acute or chronic. Instead, it is a fluctuating condition characterized
by recurrences or exacerbations of varying severity and pain-free
periods.
103
In many cases an underlying condition appears to influ-
ence propensity for symptoms and occasional flare-ups loosely
related to a variety of individual and environmental factors. This
recurrent variable nature of back pain within individuals com-
monly leads to misclassification of the presence or absence of
contributing conditions and influences occurrence rates and
observed associations with suspected risk factors.
Also important to the incidence and prevalence of low back
pain reporting in the workplace are significant overall trends in
industrial injury reporting. The mix of industrial injury claims has
changed dramatically over past decades, with increasing domi-
nance of back and other ill-defined musculoskeletal complaints
over traumatic accident-induced injuries. Ostry
78
clearly depicted
this trend in a summary of short-term work loss claims from 1952
to 1996 in British Columbia. He presented the relative number
of claims attributable to strains, which includes the categories
of back strain, overexertion, and other strains and sprains, as
compared with claims for impact (falls, slips, blows from objects,
and so forth) and other miscellaneous injuries (Fig. 4a.2). During
the years studied, a dramatic decline occurred in the proportion
Chapter 4a Incidence and prevalence 99
Figure 4a.2 Proportion of strains, impacts, and miscellaneous injuries of accepted short-term time loss claims per year in British Columbia,
1952-1996. (With permission of the Canadian Public Health Association. From Ostry A: Can J Public Health 91:36-40, 2000.)
900
800
700
600
500
400
300
200
100
0
1
9
5
2
1
9
5
4
1
9
5
6
1
9
5
8
1
9
6
0
1
9
6
2
1
9
6
4
1
9
6
6
1
9
6
8
1
9
7
0
1
9
7
2
1
9
7
4
1
9
7
6
1
9
7
8
1
9
8
0
1
9
8
2
1
9
8
4
1
9
8
6
1
9
8
8
1
9
9
0
1
9
9
2
1
9
9
4
1
9
9
6
Impact
Strain
Miscellaneous
of impact injuries from over 80% of all injury claims in the late
1960s to slightly over 30% in 1996. Conversely, claims for strains
rose from approximately 10% of all injury claims to 50%.
Overall, in recent years occupational injury and illness rates in
North America have shown a downward trend. The U.S. Survey
of Occupational Injuries and Illnesses, generated by employer
workplace incident logs, revealed a decline in nonfatal injuries in
private industry from a high of 9.2 cases per 100 full-time workers
in 1978 and 1979 to a low of 6.6 cases per 100 full-time workers in
1997, the last year for which data were analyzed.
30
Similar trends
were observed in Ontario, Canada from 1993 to 1998, where a
29% reduction in lost-time compensation claims was seen.
72
The
reasons for the decline are unclear. It has been speculated that it
could be due to more effective prevention or treatment programs
that influenced incidence or time loss, greater reluctance by
employees or employers to report incidents, or changes in criteria
for the diagnosing of some of these conditions by health care
providers.
12
The reduction may be due also to shifts in dominant
industries and more generalized economic, social, cultural, or leg-
islative trends that have affected injury reporting. Of the approx-
imately 5.7 million injuries reported in 1997, representing 93% of
all injuries and illnesses documented in employer records, how-
ever, the category of strains, sprains, and tears accounted for a
disproportionately large share of cases with days away from
work. Nearly half of these involved the back.
30
Looking specifically at low back pain claims and associated
disability and costs in North America, a downward trend has
been noted since the late 1980s. Using a large sample of claims
from the privately insured U.S. workers compensation market,
Hashemi et al
44
examined length of disability for low back pain
claims and associated costs during the period of 1988 to 1996. As
in previous studies,
88
the distribution in terms of disability and
costs was highly skewed. Depending on the year, 4.6-8.8% of
claims with a disability duration lasting over 1 year accounted
for 78-90% of the total disability days and 65-85% of the claims
costs. Over the study period from 1988 to 1996, the mean length
of disability decreased by 61%, whereas the mean and median
cost per claim decreased by 41% and 20% respectively, suggesting
that the most influential changes occurred through a reduction
in long-term disability claims. Concurrently, a 34% decrease in
the annual low back pain claim rate was reported in the United
States from Bureau of Labor and Statistics data between 1987
and 1995, although it was noted that the trend was not monoto-
nic. There was a sharper decrease in costs, one of 58%. Yet in
1995 the rate of low back claims in the United States was 1.8 per
100 employees, still representing a major health problem in the
workers compensation system.
71
These changes in back incident and claims rates seem to be a
part of the larger trend for declines in all work-related injury and
illness reporting. In Washington state, for example, there was a
decrease of approximately 24% in the incidence rate of back
claims from 1989 to 1996 and a similar decrease of 27% in all
claims during the same period.
44
Although a significant variation
exists among industry sectors, Yamamoto
107
reported a trend for
a decline in the number of recognized occupational low back
pain cases in Japan as well.
In a large study of over 730,000 claims initiated from 45 U.S.
states in 1989, available through a Liberty Mutual Insurance
Company database, back-related claims constituted 16% of all
claims and 33% of all costs.
104
Medical costs were overshadowed
by indemnity costs that represented nearly 66% of total claims
costs. These figures are similar to those from other studies reported
from the United States at around the same time
88
and somewhat
lower than figures from Australia from the early 1990s.
77
RISK FACTOR ASSOCIATIONS
Structural pathology and tissue injury
Back pain is commonly used as a synonym for spinal illness or,
in the case of the workplace, spinal injury, although it is obvious
that they are not the same and that the causal factors for the
underlying pathology and reporting of back pain can be different.
Some pain could originate from a metabolic disturbance such as
muscle fatigue, which could be expected to recover fully without
remaining identifiable pathology. Physical loading exceeding the
tolerance of a structure produces a structural pathology with pain.
This true injury and other factors, such as severe degeneration or
infections, could lead to irreversible pathologic conditions, the
symptoms of which could be triggered by routine or physio-
logic loading.
This could be one explanation for the result that previous his-
tory of back pain is one of the most consistent predictors of later
back pain.
13
Commonly used disability scores estimate avoid-
ance of defined functions due to back pain (the modifying effect
of reported physical loading on pain). The correlations of under-
lying illness with sickness absenteeism, permanent disability
pension, and use of health care due to back pain, however, are
generally low.
Clinical relevance of spine pathology
Studies of factors associated with the pathology of spinal struc-
tures have received relatively little attention, although the disk
has been commonly thought to be responsible for most back
symptoms and has been a primary target for diagnostic and ther-
apeutic interventions related to spinal disorders. Knowledge of
the macropathoanatomy and micropathoanatomy of the spine
is consequently limited with respect to painful conditions.
For example, we do not know the clinical value of osteophytes,
disk space narrowing, disk bulges, end-plate changes, interverte-
bral foramina and spinal canal anthropometry, or facet joint
degeneration. In the past decade even our understanding of the
clinical relevance of disk herniation and annular ruptures has
changed.
Some studies have shown an association between disk pathol-
ogy and back pain reporting, but degenerative findings are also
common among asymptomatic subjects.
14,16,99,105
Certain mecha-
nisms have been suggested to explain associations between disk
pathology and back pain. Full annular ruptures reaching inner-
vated disk structures could be associated with back pain through
several mechanisms. Annular tearing can lead to disk herniation
with nerve compression, has been shown to produce pain by bio-
chemical effects, and is the pathology allowing nerve ingrowth
into the disk.
5,33,34,76
Disk degeneration could make the disk
mechanically incompetent, allowing abnormal motion between
neighboring disks and leading to pain in innervated structures in
the functional unit.
73
Several other structures in the spine, such
as muscles and tendon insertions, are possible sources of back
pain. The condition underlying most back pain remains
unknown, however, and the structural changes mentioned are
currently of little clinical value.
Hereditary influences on disk degeneration
There has been a dramatic paradigm shift over the past decade with
respect to determinants of disk degeneration and pathology. This
shift is clearly depicted by the contrasting conclusions of two
reviews on the topic of degenerative disk disease written a
decade apart. After an extensive review of the literature in 1992,
Frymoyer
35
concluded, Among the factors associated with its
occurrence are age, gender, occupation, cigarette smoking, and
exposure to vehicular vibration. The contribution of other factors
such as height, weight, and genetics is less certain. A decade later
in 2002, Ala-Kokko
1
concluded, Even though several environ-
mental and constitutional risk factors have been implicated in this
disease, their effects are relatively minor, and recent family and
twin studies have suggested that sciatica, disk herniation and disk
degeneration may be explained to a large degree by genetic factors.
Traditionally, degeneration of the spine has been viewed as an
outcome of the accumulation of lifetime mechanical insults and
injuries imposed on normal aging changes. During the 1990s the
dominant effect of hereditary factors became clear, but the tradi-
tional view still maintains wide support.
1,35
The traditional view,
however, makes it difficult to explain the very high concordance
in degenerative signs observed in lumbar spine magnetic reso-
nance images in monozygotic twin pairs highly discordant for
occupational exposures. In a study of determinants of disk
degeneration in 115 pairs of identical twins, occupational physi-
cal loading explained from 0 to 7% of the variance in disk degen-
eration in the lumbar spine and age (ranging from 35 to 70 years)
below 10%, whereas the combined effect of genes and shared
environmental factors accounted for 30-60% of the total vari-
ance in disk degeneration.
11
The observed significant individual
differences at all ages in the degree of disk degeneration support
a conclusion that there are crucial individual differences in pre-
disposition to this problem. Using a classic twin study, Sambrook
et al
84
reported that heritability estimates explained 74% of the
variance of the overall score of disk degeneration of the lum-
bar spine. The results from these twin studies suggest that heredity
has a dominant role in disk degeneration compared with the
importance of all commonly suspected adulthood exposures. The
role of genetics has been confirmed additionally in several studies
identifying gene forms associated with disk degeneration.
4,51-53,97
It is likely that more genes associated with disk degeneration and
symptoms will be found over the coming years, enhancing our
chances to investigate so-called gene-environment interactions
and leading to better understanding of the etiopathogenesis of
disk degeneration.
Occupational and other influences on disk
degeneration
Most epidemiologic studies in the area of common spinal disor-
ders have been of back symptoms, and the literature related to
the epidemiology of spine pathology is limited. In an excep-
tional study of musculoskeletal findings based on 1000 consecu-
tive autopsies, the occurrence rate of spondylitis deformans
increased linearly from 0 to 72% between the ages of 39 and
70 years.
45
Although these findings relate to people and work
conditions around the turn of the century and the definition of
spondylosis is not clearly stated, the rapid linear increase is
notable. In a review article, Miller et al
68
reported a similar
increase in grades II to III disk degeneration from 0% at age 20
to about 90% at age 70 years. The authors also concluded that
radiographic data are corroborated by macroscopic findings.
Frymoyer et al
37
compared the radiographs of three groups of
men between the ages of 18 and 55 years: men with no history
of back pain, men with moderate back pain, and men with severe
back pain. In these three groups the frequency of Schmorls nodes,
claw spurs, disk heights at the L3-L4 and LS-S1 levels, the disk
vacuum sign, and transitional vertebrae were similar. The radi-
ographic findings that differed in the three groups were traction
spurs and/or disk space narrowing between L4 and L5, but these
findings did not correlate with occupation, occupational lifting,
or whole-body vibration. Specifically with respect to driving and
associated whole-body vibration, findings have been somewhat
conflicting, but the current weight of evidence suggests no
notable effect on disk degenerative findings. Arguably the most
well-controlled study to date on the subject did not find lumbar
disk degeneration or pathology to be associated with lifetime
driving.
9
Riihimaki
82
found that concrete reinforcement workers
had a relative risk of 1.8 for disk space narrowing as compared
with house painters and a relative risk of 1.6 for spondylo-
phytes. They concluded that heavy physical work enhanced the
degenerative process in the lumbar spine.
An autopsy study of 86 subjects by Videman et al
99
showed
that occupations that involved sitting, standing, and walking
without heavy physical loading were associated with the
least degeneration. Workers with heavy physical loading had
the highest incidence of annular ruptures, and sedentary
work was associated with the highest degree of general disk
degeneration.
Studies using magnetic resonance imaging reported risks of
0.35 and 0.57 at the age of 20 years among asymptomatic and
symptomatic subjects and 0.09 among asymptomatic subjects at
the age of 11 years.
79,86
In addition, Boos et al
17
demonstrated
histologically verified annular tears in a group of subjects aged
11-16 years and endplate cartilage pathology among 3 to 10 year
olds. The adjusted disk signal intensity reflecting the water con-
tent of nucleus pulposus has been shown to change rapidly in
early years between the ages of 9 and 77 years.
68,98
Obviously,
degeneration begins before individuals are exposed to workplace
factors. All adults have disk degeneration, and only the degree of
spine degeneration varies. That degenerative changes are present
already in childhood further underlines our limited understand-
ing of the etiology of spinal degeneration.
Many researchers have studied spine degeneration based on
radiography, which provides good measures of disk space nar-
rowing and annular insertions to vertebrae (osteophytes),
although its overall relevance for the intervertebral disk is not
clear. A study of more than 15,000 adults did not show that heavy
work was associated with spine degeneration in radiographs,
although men had more degenerative signs than women.
Lawrence
56
reported that lumbar disk degeneration was most
common in persons with physically heavy tasks compared with
more sedentary workers, but only in men. Hult
49
showed the
Chapter 4a Risk factor associations 101
prevalence of disk degeneration to be nearly 100% by age 59 in
workers with heavy physical work, and similar degenerative find-
ings were noted about 10 years later among those engaged in
light work. Interestingly, however, important differences between
the groups with heavy and light physical work were observed at
baseline, and firm conclusions about the relative role of occupa-
tional physical loading on disk degeneration cannot be made.
Conflicting findings in the scientific literature and failure to iden-
tify a dose-response relationship have not led to a convincing
demonstration of the primacy of workplace factors in causing
anatomic abnormalities.
10,96
SUMMARY
In principle, the determinants of all degenerative processes are
similar. A function of individual constitutional factors, including
genetics, they are modified by behaviors and extrinsic exposures.
As studies progress in the area of spinal degeneration and struc-
tural variation, genetic influences appear to play a dominant
role. Occupational exposures, representing different loading con-
ditions, alone appear to have only modest affects on disk degen-
eration and pathology. Virtually all humans are exposed to the
types of physical activities that have been suspected of accelerat-
ing lumbar degeneration during either work or leisure, with expo-
sure being simply a matter of degree. Their influences vary due to
recovery times, adaptation level, and stage of degeneration, among
other factors. It is likely also that there are as yet unknown fac-
tors contributing to degeneration. In the end, both environmen-
tal and constitutional factors have some role in all degeneration,
and only their relative magnitudes vary.
21
Work-related back pain reporting
Industrial back injury incident reports and claims filing involve
specific definitions of back problems to be distinguished from
structural pathology, symptom complaints solicited on surveys,
or problems identified through health care visits. Most developed
countries have systems for filing complaints of work-related injuries
and illnesses with their own sets of rules, costs, and benefits. In dis-
cussing such systems in the United States, Hadler
41
emphasized that
filing a complaint forces the person to conform to the workers
compensation paradigm. He stated, By definition, work task
description is causal. By inference, the illness is a manifestation
of major structural damage. As we have discussed, both of these
assumptions are highly controversial.
We found 13 prospective longitudinal studies that investigated
predictors of industrial back pain reports.
13,19,22,31,38,46,48,55,69,70,81,83,93
Early studies focused largely on physical factors, whereas more
recent research attempted to account for other factors influenc-
ing back pain reports.
Chaffin and Park
22
performed some of the earliest prospective
research in this area. In the early 1970s, they conducted a study of
back incident reports in 411 men and women who engaged in
manual lifting in their work at an electronics manufacturing com-
pany. The study focused on the effects of occupational lifting and
mismatches between individual strength and job requirements.
They reported an association between low back pain and jobs
with higher lifting strength requirements. They also found a
higher incidence of back pain reporting in persons who demon-
strated less strength on isometric strength testing than that
deemed necessary to meet job demands, as compared with those
whose strength met or exceeded demands, although the associa-
tion was not statistically significant. Limitations of this study were
that only 25 low back incidents were reported and controls for
other factors influencing back pain reports were not undertaken.
Cady et al
19
later reported on physical fitness as an indicator
of risk in 1652 firefighters over a 3-year period. Fitness was
defined by a composite score based on aerobic capacity, strength,
and flexibility measures. They found that firefighters with low
fitness levels were about nine times more likely to report a back
injury than those in the most fit group. The few injuries
reported among the highly fit were the most serious, however, in
terms of cost. Again, the effects of age, previous back pain, and
other potentially confounding factors were not reported, making
interpretation of the results difficult.
Isokinetic lifting strength was investigated as a predictor of
low back injury claims among nurses in a study by Mostardi
et al,
70
who concluded that lifting strength was a poor predictor
of subsequent back symptoms and injury reports. Another prospec-
tive study of back injury reports in nurses reported by Ready
et al
81
reached similar conclusions about isometric lifting strength
and other general fitness parameters. The factors that discrimi-
nated most between the nurses who did and did not report sub-
sequent back injuries were previous receipt of compensation,
smoking status, and poorer job satisfaction.
In the Boeing study, a prospective cohort study of industrial
back pain complaints in 3020 aircraft manufacturing workers,
isometric lifting strength, maximal aerobic capacity, and lumbar
range of motion were among the factors that were not associated
with subsequent complaints. Other than having had current or
recent back problems at the onset of the study, the strongest pre-
dictors of future back pain reports were negative perceptions of
the workplace, including low job task enjoyment and social sup-
port and emotional distress.
13
The only factor from the baseline
physical examination that was strongly associated with future
reporting was back pain elicited on straight leg raise testing,
which probably represents another aspect of recent or current back
problems also known to influence future risk.
7
Yet in multivariable
analysis, considering the numerous suspected risk factors under
investigation, less than 10% of the variance in the reporting of
work-related back pain was explained. The study findings under-
line the multifaceted nature of back pain reporting in industry and
the limited predictive ability of most suspected risk factors.
A later extension of the Boeing study looked specifically at
back incident reports that resulted in the formal filing of indus-
trial insurance claims. Lower job satisfaction and a poorer
employee appraisal rating by the employees immediate supervi-
sor were associated with back injury claims. Given the findings
of the earlier analysis of back incident reports, this result was not
surprising. A more notable finding of the later analysis was that
these psychosocial factors were similarly associated with
nonback injury claims as well. It would appear that certain psy-
chosocial factors may predispose to the filing of injury claims,
but the study did not provide evidence of significant differences
between those who filed back injury claims and those who filed
other types of injury claims.
9
Such findings caution against
stereotyping persons who file back injury claims as being dis-
tinctly different from those filing other injury claims with respect
to preinjury psychosocial factors. As Leavitt
57
stated, The
unfortunate problem is that stereotypes have consequences.
Doubts raised by labels often shape evaluation and treatment of
industrial workers in problematic ways, to the extent that their
integrity and status as patients is challenged.
Since the Boeing study, researchers have continued to search
for risk indicators and have expanded the investigation more
fully into multiple domains including the physical, social, and
psychologic. Numerous potential risk indicators, including expo-
sure to repetitive trunk rotation, low supervisor support, and lack
of control over work duties, have been reported. Many of these
indicators have been found through exploratory studies, how-
ever, and few results have been taken to the next crucial stage of
confirmation or replication in a separate cohort. Exploratory
investigations have many inherent risks, including observing sta-
tistically significant associations by chance that do not actually
exist or are biologically implausible.
2
More trust can be placed in
findings that have been validated through confirmation studies.
Although confirmation studies in this area of research are
rare, six indicators have been reported in multiple studies to
increase the probability of future back pain reports: low job sat-
isfaction,
13,48,55,81,83
heavy physical work requirements,
31,38,55,69
low social support at work,
13,93
previous low work performance
ratings,
13,55,93
smoking status,
8,81,93
and previous history of low
back problems.
13,83,93
The magnitudes of each of these associa-
tions have been relatively low, with odds or rate ratios typically
ranging between 1.5 and 3.0 and accompanied by confidence
intervals approaching 1.0. It is clear also that individual worker
strength levels do not predict future injury.
7,69,70,81
Although the
above results have been substantiated in multiple investigations,
it is unknown whether the associations observed indicate causal
relationships, especially regarding the psychosocial and physical
indicators. Although theories abound for how both psychosocial
and physical stressors could result in reports of back pain, it is
possible that indicators from within one domain influence indi-
cators within the other. It has been theorized that individuals
with higher workloads may be more likely to have lower job satis-
faction.
27
Alternatively, individuals under psychologic stress may
be exposed to altered biomechanical forces through changes in
posture or movement strategies.
66
Further research is required to
clarify the potential interactions arising between physical and
psychosocial indicators. One study in which interaction effects
between predictor variables were studied found independent
effects of both psychosocial and physical variables, possibly
indicative of unique effects for each.
55
Although some work has been done to elucidate which
factors are associated with industrial back pain reporting, the
practical value of predictive models or preemployment screening
for identifying specifically who will or will not experience or
report symptoms is questionable. The magnitude of associations
for individual predictor variables and overall predictive accuracy
of created models has been relatively low, and practical difficul-
ties arise when attempting to apply results from large samples
to individual workers. Additionally, attempts at prevention
based on knowledge of suspected risk factors such as workplace
ergonomic modification have been largely unsuccessful.
26,64,94
In
fact, authors of one systematic review evaluating the effectiveness
of multiple prevention strategies stated, The results concerning
prevention for subjects not seeking medical care are sobering.
Only exercises provided sufficient evidence to conclude that
they are an effective preventive intervention.
60
Subsequent disability
Evidence suggests that back symptoms have always been present
to some degree among humans and likely always will be.
Episodes of these symptoms are, however, typically manageable
and relatively short-lived. A systematic review of the prognosis of
acute (<3 weeks) low back pain indicated that the prognosis of
this condition is largely positive.
80
Although back pain is a recur-
ring phenomenon, most individuals recover from episodes
quickly and experience little disability. The vast majority
(68-86%) of individuals off work due to back pain returns to
work within 1 month, and further improvements are seen for up
to 3 months. In the small minority experiencing pain and dis-
ability for 3 consecutive months, however, little further improve-
ment in important clinical outcomes is seen. Although some
chronic back pain sufferers are able to cope with their pain and
continue to work, a portion remains off work and experiences
extended time loss.
20
Within the workplace, it has been reported
that approximately 10% of back injury claimants with extended
work loss account for approximately 10% of back-related indus-
trial insurance costs.
88
Long-term disability is therefore the out-
come that poses the greatest threat to the individual and the
greatest cost to society.
Disability is typically represented in the work environment as
absenteeism. An examination of factors associated with illness
absenteeism led Backenheimer
6
to conclude that absence
behavior is, in considerable measure, a cultural and social phe-
nomenon. He claimed also that a biological frame of reference
is too narrow to explain the condition of being ill. There is now
a large body of evidence that these notions apply also to absen-
teeism and disability from back problems. Great variability is
observed in back pain disability and work loss durations among
nations and disability systems that would not be expected if dis-
ability were purely a biologic phenomenon.
47,100
Long-term back
pain disability is a relatively new phenomenon in the history of
Western civilization, and its dramatic growth since World War II
suggests that factors other than physical pathology are influenc-
ing its development. This is not to say that many working people
do not genuinely experience back pain or that severe symptoms
do not cause physical limitations of some duration. On the con-
trary, numerous health surveys indicate that back symptoms are
extremely common in both developed and Third World coun-
tries.
3,75,101
What appears to have changed in many societies, how-
ever, is the public perception of back pain as an injury or
medical problem and its effect on work life in terms of disability.
One striking example of the tremendous growth in back pain
disability seen in many of the developed countries comes from
the U.S. Social Security Disability Insurance System, where from
1957 to 1976 the incidence of disability awards increased by
approximately 270%, a rate 14 times that of the population
growth (Fig. 4a.3).
87
Similarly striking increases in the incidence
of disability awards have occurred in Finland, Sweden, and
England.
74
Although there is some evidence that the increasing
Chapter 4a Summary 103
trends have leveled or reversed, disability associated with back
pain remains widespread.
71
Factors other than just the presence of back symptoms influ-
ence back symptom reporting and long-term disability. Multiple
literature reviews have been published examining what factors are
related to prolonged disability or work loss.
25,59,92
Consistently, a
multifactorial model of disability incorporating factors from
physical, social, psychologic, and occupational domains is advo-
cated. Of likely importance to the onset and persistence of dis-
ability are cultural norms; socioeconomic conditions, including
unemployment rates and opportunities for compensation; and
physical and psychosocial work environments.
25,54,59,101
Many
studies seeking to identify predictors of prolonged disability
have enrolled subjects already in subacute or chronic states,
however, thus confounding results and reducing generalizability
to more acute cases. The authors of a systematic review of acute
back pain prognosis reported identifying only one study of high
methodologic quality that included a clinically relevant predic-
tor.
80
Clearly, further research is needed to accurately identify
acute back pain patients at risk of developing chronic conditions.
Compensation availability appears to affect the length of dis-
ability in the case of both surgical intervention
32,43
and conserva-
tive care.
39,42
However, Leavitt
57
noted that most studies citing an
association between compensation and back pain reporting and
disability failed to take into account the effects of physical
demands of the job; these can affect the outcome and differ sig-
nificantly between compensation and noncompensation groups.
He attempted to disentangle the effects of these factors and
found that work-related back symptom reports were associated
with more time loss than were nonwork-related back symptoms,
even after controlling for the degree of physical job demands. In
addition, a related literature synthesis by Loeser et al
62
concluded
that when all other factors are held constant, the existing
economic studies imply a positive relationship between the level
of wage replacement benefits and both the incidence and duration
of workers compensation claims. The relative effect of benefit
level appeared to be greater on claim duration than on claim inci-
dence. This suggests that a key issue for workers compensation
systems to contend with may be determining an optimal wage
replacement ratio.
Inappropriate medical management has been implicated also
as a contributor to the growing disability problem. The rise in
disability and increasing health care costs and utilization despite
advances in medical technology led Frymoyer and Cats-Baril
36
to
raise the question, Have medical professionals of all types
become part of the problem rather than part of the solution?
Erroneous back pain beliefs of both health care professionals and
the general public, including frequent suspicions of and investi-
gations for major pathology and fear-avoidant beliefs in cases of
simple back pain, appear to influence back pain disability.
61
In
regards to the desynchrony between current evidence-based
treatment guidelines and popular opinions, Deyo
28
stated, The
new back pain guidelines represent such a substantial shift from the
traditional approach that the public will need to be re-educated.
Indeed, a recent public reeducation attempt through a social
marketing campaign in Victoria, Australia, which portrayed the
positive prognosis of back pain and conveyed the importance of
staying active, was effective in altering beliefs and reducing work-
related disability.
18
CONCLUSION AND IMPLICATIONS
Back pain continues to be a major burden for developed coun-
tries. Since the earlier version of this chapter was written for the
first edition of this book, further epidemiologic studies have
been undertaken in an attempt to understand the prevalent and
costly condition of low back pain. Because they substantially
alter the conceptualization of occupational back pain, several
discoveries are particularly noteworthy.
First, lumbar spine degeneration, long considered a conse-
quence of the accumulation of mechanical insults and injuries,
Figure 4a.3 Social Security Disability Insurance awards by diagnosis: percent increase from 1957 to 1976. (From Fordyce WE: Back pain,
compensation, and public policy. In JC Rosen, LJ Solomon, eds: Prevention in health psychology. Hanover, NH, 1985, University Press of
New England.)
mainly from occupational exposures, has been found to be
influenced in large part by heredity. The clinical implications of
these findings include an altered conceptualization of the etiol-
ogy of lumbar spine degeneration. Medical imaging findings that
were once commonly attributed to occupational exposures can
no longer be explained as such. Current evidence suggests that
the role of occupational loading exposures is relatively minor in
comparison with genetic influences.
Second, the search for risk indicators has continued to result
in inconsistent findings, identifying relatively small roles for envi-
ronmental factors in explaining work-related back pain reporting
and associated disability. These findings are contrary to earlier
views that ascribed back pain incidents to excessive occupational
physical loading requirements (either peak or repetitive). Thus it
is not currently possible to predict which workers will experience
back pain in a given occupation and which will experience
delayed recovery.
Finally, although the global experience of work-related back
pain reporting and associated disability varies markedly by coun-
try or jurisdiction, over the past decade or so, for which figures
are available, there has been an overall decline in some countries.
This decline comes after many decades of growth. Recent trends
in North America indicate that incidence and disability related
to back injury claims, and time loss claims in particular, have
declined over the past 10 years or so that data have been ana-
lyzed. However, this decline is part of one observed in all indus-
trial injury and illness claims.
The phenomena of work-related back pain incident reports,
claims, and disability are influenced by socioeconomic, cultural,
and broad legislative and jurisdictional factors. When comparing
incidence and prevalence figures between nations and jurisdic-
tions, great variations are thus observed. For this reason, the
role of dominant paradigms through which back pain is viewed,
particularly as it pertains to work, and the systems through which
persons file related complaints must be acknowledged. Such
factors constitute inherent biases in studies of the role of occu-
pational exposures that must be recognized in planning epidemi-
ologic studies and interpreting resulting data.
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Compressive failure, particularly in an osteoporotic individual,
occurs in this region.
The other major component of the anterior portion of the
FSU is the intervertebral disk. The function of the disk is to dis-
tribute loads and restrain excessive motion. The disk is composed
of the annulus fibrosus and nucleus pulposus. The annulus is
made up of a series of sheets of collagen fibers, with the fibers of
one sheet at a 30-degree angle relative to the neighboring sheet.
Mathematical models show that with removal of the nucleus,
interval stresses ensue as a result of the compressive forces being
carried through the annulus. The inner portion of the disk,
the nucleus pulposus, is rich in hydrophilic glycosaminoglycans
in young adults, but with age the nucleus pulposus becomes
progressively less hydrated.
Animal experiments have shown that disks are avascular struc-
tures and that endplate permeability decreases with age, thereby
decreasing disk nutrition. Motion is beneficial for intervertebral
disks. Solute transport and metabolism are both improved by
spinal motion, and intermittent motion is less effective than
continuous motion. Aging usually results in disk degeneration.
Degeneration of a disk reduces its proteoglycan content and
thus its hydrophilic capacity. As the disk becomes drier, its elastic-
ity and its ability to store energy and to distribute loads gradually
decreases. Most disk herniations occur in the fourth decade of life,
and herniations are found in 15 to 30 of autopsy specimens.
The intervertebral disk exhibits creep, which means that the
disk continues to deform under a constant load. This time-
dependent behavior comes from the fluid flow of the disk under
an applied load and from the inherent viscoelastic behavior of
the collagen and proteoglycan matrix. Time-dependent behavior
has been demonstrated both in vivo by Keller et al
8
and in vitro
by Kazarian.
7
The studies of Eklund and Corlett
3
and Krag et al
10
indirectly measured the change in overall height of the subjects.
The diurnal loss was about 17 mm. Kazarian
7
noted that a degen-
erate disk had a higher rate of deformation and the creep curve
stabilized sooner.
Virgin
17
was the first to suggest that the nucleus pulposus acts
hydrostatically to pressurize the disk and thus stabilizes the FSU.
In a nondegenerate disk, nucleus pressure is redistributed as ten-
sion in the annulus layers. Normal disk pressure is about 1.5
times the compressive load divided by the cross-sectional area.
Pressure is higher in the disk center and decreases toward the
exterior. Nachemson
15
reported that disk pressure is different in
various positions or maneuvers (Table 4b.1). Andersson et al
1
found in vivo that intradiskal pressure increased linearly with an
increase in both trunk load and trunk moment. Disk pressure
was found to be high in unsupported sitting but decreased
significantly with the use of a backrest inclination greater than
110 degrees, with the use of lumbar supports, and with the use
of armrests. The tensile stress in the annulus fibrosus due to disk
pressure in the thoracic spine is less than that in the lumbar spine
because the higher ratio of disk diameter to height in the thoracic
disks reduces the circumferential stress.
11
Posterior portion
The posterior portion of the FSU has a primary role of guiding
its movement. The type of motion possible at any level is
C HA P T E R
4b
Clinical Biomechanics
of the Spine
Malcom H. Pope
The spine is an important structure with many conflicting
functions. The first function, mobility, provides the motion
necessary for the activities of daily living. The second function is
one of support for the body segments and any load moments
that are applied by the worker. The third function is housing,
in which the spinal cord and nerve roots are protected. The last
function is control, with the muscles acting through the vertebrae
to precisely control the posture.
FUNCTIONAL SPINAL UNIT
The functional spinal unit (FSU) consists of two adjacent vertebrae,
the interposed vertebral disk, and adjoining ligaments. The motion
segment can be divided into anterior and posterior components.
The anterior components are the vertebral bodies, the disk, and
the attached ligaments; all the remaining structures are posterior
components.
19
The FSU is a structure in which the disk acts as a spring, the
facet joints as a pivot, and the posterior ligamentous complex as
another spring. Experiments have shown that the FSU exhibits
coupled motion in which vertical translation also results in complex
movements in other directions. The anterior elements of the FSU
have a support function and a function of impact absorption,
whereas the posterior elements control motion.
Anterior portion
The major structural part of the anterior portion of the FSU
consists of the vertebral bodies. These bear mainly compressive
loads and are progressively larger caudally as the weight of the
upper body increases (Fig. 4b.1). Therefore, the vertebral bodies
in the lumbar region are bigger than those in the thoracic
and cervical regions. Compressive strength concomitantly
gradually increases from the cervical spine down to the lumbar
spine. Overall, the vertebrae are six times stiffer than the disks,
three times thicker than the disks, and suffer half the deforma-
tion of the disks. The vertebrae are very important in shock
absorption. Under compression, endplate deformation precedes
the expelling of hematopoietic contents from the vertebrae
themselves.
The vertebrae are an expression of Wolff s law inasmuch as the
trabeculae are oriented to resist the vertical compression forces
and tensile forces through the spinous and transverse processes
caused by muscle and ligament attachments. There is a zone
of relative weakness anteriorly because of a lack of trabeculae.
determined by the orientation of the facets of the FSU to the
transverse and frontal planes. This orientation changes throughout
the spine (Fig. 4b.2).
Other structures that influence motion of the spine are the rib
cage, which limits thoracic motion, and the pelvis. The cervical
spine, the most mobile region of the spine, affords the head a
large range of motion, which is necessary for the activities of
daily living. Except for the facets of the two uppermost cervical
vertebrae (C1 and C2), which are parallel to the transverse plane,
the cervical facets are oriented at 45 degrees to the transverse
plane and are parallel to the frontal plane (Fig. 4b.2). The load-
bearing function of the facets at all spinal levels is significant.
Chapter 4b Clinical biomechanics of the spine 108
C3
C4
C5
C6
C7
T1
T2
T3
T4
Messerer, 1880
Perry, 1957
Bell et al, 1967
T5
V
e
r
t
e
b
r
a
l

l
e
v
e
l
T6
T7
T8
T9
T10
T11
T12
L1
L2
L3
L4
L5
0 2000
(450 lbf)
4000
(900 lbf)
6000
(1350 lbf)
8000
(1800 lbf)
Compression strength in newtons (pound force)
Figure 4b.1 Vertebral compression strength at a slow loading rate. (Modified from White AA, Panjabi MM: Clinical biomechanics of the spine.
Load sharing between the facets and the disk varies with the posi-
tion of the spine. The loads on the facets are very high, peaking
at about 30% of the total load when the spine is hyperextended.
9
They are also quite high during forward bending coupled with
rotation.
4
The facets through the vertebral arches and intervertebral
joints play an important role in resisting shear forces. In addition,
Farfan
5
showed that 40% of the torsional strength of the FSU
come from the facet joints, and Lorenz et al
12
suggested that 25%
of the axial load bearing is from these structures.
Ligaments
The spine ligaments function in conjunction with other elements
of the FSU as stabilizers and check reins. They are tensile elements
that can fatigue, and they do contain pain fibers. The overall
load deflection curve on the FSU is nonlinear, being reflective of
ligament behavior. Extension loads the anterior ligaments and
flexion loads the posterior elements.
During flexion, the interspinous ligaments have the greatest
strain, followed by the capsular ligaments and the ligamenta flava,
whereas in extension the anterior longitudinal ligament bears the
greatest strain. During lateral flexion, the contralateral transverse
ligament is strained the greatest, followed by the ligamenta flava
and the capsular ligaments. The capsular ligaments bear the most
Chapter 4b Functional spinal unit 109
Table 4b.1 Loads on the L3 disk calculated from
intradiskal pressure measurements in a 70-kg man
Position, Maneuver Load (N)
Supine (awake) 250
Supine (semi-Fowler) 100
Supine (traction, 500 N) 0
Sitting (unsupported) 700
Standing (relaxed) 500
Coughing 600
Straining 600
A
B
C
45
0
20
45
Cervical
(C3-C7)
Thoracic
Lumbar

60
90
Orientation of the
facets to the
transverse plane
Orientation of
the facets to
the frontal plane
Figure 4b.2 Orientation of the facets of the
intervertebral joints. (A) In the lower cervical spine
the facets are 45 degrees to the transverse plane
and are parallel to the frontal plane. (B) The facets of
the thoracic spine are oriented at 60 degrees to the
transverse plane and at 20 degrees to the frontal plane.
(C) The facets of the lumbar spine are oriented at
90 degrees to the transverse plane and at a 45 degree
angle to the frontal plane. (From White AA, Panjabi MM:
Clinical biomechanics of the spine, 1991, JB Lippincott.)
strain during rotation. The ligamentum flavum, which connects
two adjacent vertebral arches longitudinally, is an exception in its
behavior because it contains a large percentage of elastin. The
elasticity of this ligament is therefore very high. This allows it to
contract during extension of the spine and elongate during flexion.
In a neutral position, the ligamentum flavum is under tension as
a result of its elastic properties. Because it is located at a distance
from the center of motion in the disk, it prestresses the disk and
thus adds to overall stability.
KINEMATICS
The range of motion of the spine varies from level to level.
White and Panjabi
19
summarized these data (Fig. 4b.3). Flexion
and extension are about 4 degrees in the upper thoracic, about
6 degrees in the midthoracic, and about 12 degrees in the lower
thoracic segments. This increases in the lumbar motion segments
to a peak of 20 degrees at L5-S1. Lateral flexion varies from level
to level quite markedly but is greatest in the lower thoracic seg-
ments and L3-L4 (8 to 9 degrees). In the upper thoracic segments
the range is 6 degrees. Rotation is greatest in the upper segments
of the thoracic spine (9 degrees). The range of rotation is minimal
in the lumbar spine because of facet orientation. The lumbar spine
is susceptible to injury from rotation.
There have been reports of coupled motion throughout the
spine. Coupling refers to a primary motion in one direction lead-
ing to a secondary motion in another. For example, C1 moves
independently of the rest of the cervical spine, but motion below
C1 involves the entire cervical spine. The facets guide the motion,
and as a result flexion-extension is coupled with transverse trans-
lation, lateral flexion with rotation (Fig. 4b.4), and rotation with
axial translation. In the thoracic region, rotation is associated with
lateral flexion, especially in the upper thoracic region. In this
case, the vertebral bodies generally rotate toward the concavity
of the lateral curve.
18
Coupling of rotation and lateral flexion
occurs in the lumbar spine, with the vertebral bodies rotating
toward the convexity of the curve.
13
KINETICS
The basic building materials of the spine are the vertebral bodies,
which take the loads of compression, shear, and bending, and the
muscles which act as the building blocks in tension. The muscles
position and stabilize the spine. Without muscles, the ligamentous
spine buckles under loads of as small as 2 kg. In general, the
muscle electrical activity electromyographic (EMG) amplitude is
directly proportional to the moment arm of the muscle line of
action from the center of rotation. We can investigate the role of
muscle around the periphery through a free-body analysis in which,
mathematically at least, the body is cut in two and the forces and
moments are resolved across that cut surface. Forces are estimated
from the electromyographic signals. In complex postures, very high
antagonistic activity occurs. Loads are also produced by body
weight, prestress from ligaments, and externally applied loads.
0
OC - C1
C1 -2
2 - 3
3 - 4
4 - 5
5 - 6
6 - 7
C7 - T1
T1 - 2
2 - 3
3 - 4
4 - 5
5 - 6
6 - 7
7 - 8
8 - 9
9 - 10
10 - 11
11 - 12
T12 - L1
L1 - 2
2 - 3
3 - 4
4 - 5
L5 - S1
10 20 0 10 20 0
Flexion-
extension
Lateral
flexion
Rotation
10 20
Figure 4b.3 A composite of representative
values for type and range of motion at
different levels of the spine. (Modified from
White AA, Panjabi MM: Clinical biomechanics
of the spine. Philadelphia, 1991, JB Lippincott.)
Because the lumbar spine is the main load-bearing area and the
most common site of pain, studies have focused on this region.
Loads on the cervical spine are mainly produced by the weight
of the head, the activity of the surrounding muscles, the inherent
tension of adjacent ligaments, and the application of external
loads. Investigations in vivo confirm that physiologic loads are
lower than those on the thoracic and lumbar spines.
However, quite large loads on the cervical spine have been
calculated during neck flexion, particularly in the lower cervical
motion segments. Harms-Ringdahl
6
calculated the bending
moments generated around the axes of motion of the atlantooc-
cipital joint and the C7-T1 motion segment with the neck in
flexion, neutral position, and extension (Fig. 4b.5). The load on
the junction between the occipital and C1 was lowest during
extreme extension and highest during extreme flexion. The load
on the C7-T1 motion segment was low with the neck in the neu-
tral position but tucked in (ranging from an extension moment
of 0.8 Nm to a flexion moment of 0.9 Nm). The load increased
substantially during slight flexion (reaching 6 Nm).
Moroney et al
14
studied subjects who resisted loads.
Calculation of the maximum (compressive) reaction forces on
the C4-C5 motion segment ranged from 500 to 700 N during
flexion, rotation, and lateral bending and rose to 1100 N during
extension.
Body position also affects the magnitude of the loads on the
lumbar spine. These loads are minimal during well-supported
reclining, remain low during relaxed upright standing, and rise
during sitting (Fig. 4b.6).
Trunk flexion increases the load by increasing the forward-
bending moment on the spine. The forward inclination of the
spine also makes the disk bulge on the concave side of the spinal
curve and retract on the convex side. Hence when the spine is
flexed, both compressive and tensile stresses on the disk increase.
1
Nachemson and Elfstrm
16
and Andersson et al
2
also showed
that during relaxed unsupported sitting, the loads on the lumbar
spine are greater than during relaxed upright standing. In this
position the pelvis is tilted backward and the lumbar lordosis
straightens the upper body, thereby creating a longer lever arm for
the weight of the trunk.
Chapter 4b Kinetics 111
Left lateral
flexion
Neutral Right lateral
flexion
Figure 4b.4 Coupled motion during lateral flexion is depicted
schematically. When the head and neck are flexed to the left, the
spinous processes shift to the right, indicating rotation. The converse
is also illustrated. (Modified from White AA, Panjabi MM: Clinical
biomechanics of the spine. Philadelphia, 1991, JB Lippincott.)
Slight flexion:
OCC C1
1.4 Nm
(0.8 1.7)
C7 T1
3.7 Nm
(3.0 6.2)
Neutral:
OCC C1
1.3 Nm
(0.6 1.5)
C7 T1
1.2 Nm
(0.5 2.2)
Figure 4b.5 Extension and flexion moments around the axes of
motion of the atlantooccipital (OCC-C1) joint and the C7-T1 motion
segment (marked with Xs) are presented for five positions of the head:
extreme flexion, slight flexion, neutral, head upright with the chin
tucked in, and extreme flexion. Values shown are the medial and range
for seven subjects: Negative values indicate extension moments. The
arrows represent the force vectors produced by the weight of the head.
(Modified from Harms-Ringdahl K: On assessment of shoulder exercise
and load-elicited pain in the cervical spine. Biomechanical analysis of
load-EMG-methodological studies of pain provoked by extreme position.
Thesis, 1986, Karolinska Institute, University of Stockholm.)
Figure 4b.6 The relative loads on the third lumbar disk for living
subjects in various body positions are compared with the load during
upright standing, depicted as 100. (Modified from Nachemson A,
Elfstrm G: Intravital dynamic pressure measurements in lumbar discs:
a study of common movements, maneuvers and exercises. Stockholm,
1970, Almqvist & Wiksell.)
The loads on the lumbar spine are lower during supported
sitting than during unsupported sitting because part of the weight
is supported by the backrest. Backward inclination of the backrest
and a lumbar support further reduce the loads (Fig. 4b.7).
2
Because user requirements vary, the kinds of chairs available
also vary widely. Regardless of use, however, it is important to be
able to adjust any chair to meet the basic anthropometric dimen-
sions of the worker. A proper seat height is desirable and should be
adjustable for the individual user. The seat surface should be 3 to
5 cm below the knee-fold when the lower limb is vertical. Foot sup-
ports can be used with higher chairs. The width of the seat should
be sufficient to accommodate the user. It must be possible to use
the backrest, so the seat pan should not be too deep. Pressure
should be avoided on the back of the thigh near the knees.
Lifting creates the highest loads on the lumbar spine, and
these are the occupational exposures with the greatest incidence
of low back pain injury reports. The key to prevention is to reduce
the load moment, which means reducing either the magnitude of
the load, the distance from the body, or both. Therefore, if objects
of the same weight, shape, and density but of different sizes are
held, the lever arm for the force produced by the weight of the
object is longer for the larger object and the bending moment on
the lumbar spine is greater (Fig. 4b.7).
DISCUSSION
The spine has functions of load bearing, protection of neural
elements, and mobility yet stability. The FSU, which is the basic
unit, exhibits coupled motion. It is composed of the anterior com-
ponents (vertebral body, disk, pedicles, and ligament), and the
remainder make up the posterior elements. Motion, which is largely
controlled by the facet, varies between regimes. Flexion-extension
is high in the lumbar spine, but rotation is minimal. Loads in
the spine are a function of body mass, muscle activity, prestress,
and external loads. The latter is particularly important in the
lumbar spine.
REFERENCES
1. Andersson GBJ, Ortengren R, Nachemson A: Intradiscal pressure, intra-abdominal
pressure and myoelectric back muscle activity related to posture and loading.
Clin Orthop 129:156-164, 1977.
2. Andersson GBJ, Ortengren R, Nachemson A, Elfstrom G: Lumbar disc pressure and
myoelectric back muscle activity during sitting. I. Studies on an experimental chair.
Scand J Rehabil Med 6:104, 1974.
3. Eklund JAE, Corlett EN: Shrinkage as a measure of the effect of load on the spine.
Spine 9(2):189-194, 1985.
4. El-Bohy AA, King AI: Intervertebral disc and facet contact pressure in axial torsion.
In SA Lantz, AI King, eds: Advances in bioengineering. New York, 1986, American
Society of Mechanical Engineers, pp. 26-27.
5. Farfan HF: Mechanical disorders of the low back. Philadelphia, 1973, Lea & Febiger.
cervical spine. Biomechanical analysis of load-EMG-methodological studies of pain
provoked by extreme position. Thesis, 1986, Karolinska Institute, University of
Stockholm.
7. Kazarian L: Dynamic response characteristics of the human vertebral column: an
experimental study of human autopsy specimens. Acta Orthop Scand Suppl 146,
1972.
8. Keller L, et al: In vivo creep behavior of the normal and degenerated porcine
intervertebral disc-a preliminary report. J Spinal Disorder 1(4):267-278, 1989.
9. King AI, Prasad P, Ewing CL: Mechanism of spinal injury due to caudocephalad
acceleration. Orthop Clin North Am 6:19, 1975.
10. Krag MH, Cohen MC, Pope MH: Load-induced changes in human intervertebral disc
height in-vivo: a new and closer look. Orthop Trans 9(3):516, 1985.
11. Kulak RF, Schultz AB, Belytschko T, Galante J: Biomechanical characteristics of verte-
bral motion segments and intervertebral discs. Orthop Clin North Am 6:121, 1975.
12. Lorenz M, Patwardhan A, Vanderby R: Load-bearing characteristics of lumbar facets
in normal and surgically altered spinal segments. Spine 8:122, 1983.
13. Miles M, Sullivan WE: Lateral bending at the lumbar and lumbosacral joints.
Anat Rec 139:387, 1961.
14. Moroney SP, Schultz AB, Ashton-Miller JA: Analysis and measurement of neck loads.
J Orthop Res 6(5):713-720, 1988.
15. Nachemson A: Lumbar interdiscal pressure. In MIV Jayson, ed: The lumbar spine
and back pain. London, 1987, Churchill Livingstone, p. 191.
16. Nachemson A, Elfstrm G: Intravital dynamic pressure measurements in lumbar
discs: a study of common movements, maneuvers and exercises. Stockholm, 1970,
Almqvist & Wiksell.
17. Virgin WJ: Experimental investigations into the physical properties of the intervertebral
disc. J Bone Joint Surg 33B:607-611, 1951.
18. White AA: Analysis of the mechanics of thoracic spine in man. An experimental study
of autopsy specimens. Acta Orthop Scand Suppl 127:1-105, 1969.
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JB Lippincott.
A
Disk pressure
B C D E
Figure 4b.7 Influence of backrest inclination and
back support on loads on the lumbar spine in terms
of pressure in the third lumbar disk during supported
sitting. (A) Backrest inclination is 90 degrees, and disk
pressure is at a maximum. (B) The addition of lumbar
support decreases disk pressure. (C) Backward
inclination of the backrest to 110 degrees but with no
lumbar support produces less disk pressure. (D) The
addition of lumbar support with this degree of backrest
inclination further decreases the pressure. (E) Shifting
support to the thoracic region pushes the upper part
of the body forward, moves the lumbar spine toward
kyphosis, and increases disk pressure. (Modified from
Andersson GBJ, Ortengren R, Nachemson A: Clin Orthop
129:156-164, 1977.)
Initial Evaluation of the
Low Back Region
Marek Szpalski, Federico Balagu, Robert Gunzburg,
and Dan M. Spengler
Although patient evaluation and management have been clearly
improved by the explosive growth in technology over the past
decades, the hallmark of patient assessment continues to reside
in the fundamentals of the history and physical examination.
The information provided in this chapter emphasizes the impor-
tance of these basic skills to attempt to motivate the reader to
continue to improve and update this important knowledge area.
The focus of this chapter is the clinical assessment of patients
who seek an evaluation of low back pain, with an emphasis on
occupational aspects.
Another relevant aspect that has become increasingly important
in the last decades is the point of view of the patients. An impor-
tant volume of literature devoted to this topic has been reviewed
recently. In their systematic review of qualitative and quantitative
studies, Verbeek et al
72
highlighted the major patient expectations,
specifically diagnosis, instructions, and interpersonal management.
This information is important for the individual clinician.
It is important to remind the clinician that the variables
elicited by history taking and through a clinical examination
C HA P T E R
4c
have some specific properties (sensitivity and specificity) as well
as those depending on the prevalence of the disease considered
(predictive value) in the population being evaluated. Basically,
signs and symptoms (or any other test) with very high sensitivity
allow the clinician to rule out the target disease when the test is
negative. On the contrary, when the specificity of a test is extremely
high, a positive result rules in the target disease.
21
HISTORY
Two reviews of patient histories reported that although 2% to 3%
of the causes of low back pain are nonmechanical, these etiologies
must be considered most seriously and diagnosed quickly.
20,22
All
the factors that might be relevant because of their association
with increased risk of cancer, infection, or other complications
should be included in the history.
20
In a study of almost 2000 back pain patients, Deyo
21
found
that no cancer was identified among those under age 50 without
a history of cancer, unexplained weight loss, or failure of conser-
vative therapy (combined sensitivity of 100%). The elements
suggesting a diagnosis of specific low back pain are commonly
designated in the literature as red flags (Table 4c.1).
6
Concluding that a patient suffers from nonspecific low back
pain once the clinician has reasonably excluded red flags seems
to be rather unsatisfactory for most health care providers, who
do not believe nonspecific low back pain to be one condition.
42
It has been shown, moreover, that a comprehensive medical
assessment is not predictive of return to work after an episode of
occupational low back trouble.
34
For all patients who are examined for an evaluation of low
back pain with or without sciatica, a history of the present illness
should be completed, including information regarding the nature
Table 4c.1 Red flags for potentially serious conditions
Possible fracture Possible tumor or infection Possible cauda equina syndrome
From medical history:
Major trauma such as vehicle accident Age over 50 or under 20 Saddle anesthesia
or fall from a height History of cancer Recent onset of bladder dysfunction such as
Minor trauma or even strenuous lifting Constitutional symptoms such as recent fever or chills urinary retention, increased frequency, or
(in older or potentially osteoporotic or unexplained weight loss overflow incontinence
patients) Risk factors for spinal infection: recent bacterial infection Severe or progressive neurologic deficit in the
(e.g., urinary tract infection) intravenous drug abuse, lower extremity
or immune suppression (from steroids, organ
transplantation, or human immunodeficiency
virus infection)
Pain that worsens when supine; severe nighttime pain
From physical examination:
Unexplained laxity of the anal sphincter
Perianal/perineal sensory loss
Major motor weakness: quadriceps
(knee extension weakness); ankle plantar
flexors, evertors, and dorsiflexors (footdrop)
of symptom onset. The absence of sciatica or femoral nerve radic-
ular pain makes a clinically important disk herniation very unlikely
(sensitivity about 0.95 and specificity 0.88).
21
In addition, the examiner should document various treatment
approaches and the effects of the treatments on symptoms. The
reason for the evaluation and any anticipated outcomes must be
understood in advance by both the physician and the patient.
If the evaluation is for an independent medical evaluation, for
example, the patient needs to understand its purpose of provid-
ing an independent objective assessment for a third party and
that treatment is not included. The evaluation may be to assist
another physician in patient management or solely to provide an
insurance company or a workers compensation carrier with a
diagnosis and recommendations. When related to swirling litiga-
tion and compensation issues, a history must usually be more
detailed than one obtained solely to diagnose symptoms and
manage a patient. If a patient falls at home and seeks evaluation,
for example, the history might be succinct and relate only the type
and distance of the fall. In a contested on-the-job injury encounter,
the details may be more important for dispute resolution. Was the
fall witnessed? Did the employee return to work? For how long?
Is an attorney involved? Who are the physicians or others who
have evaluated the patient? Has the employee had a previous
injury? Has an impairment been recorded previously?
An interview with a patient who is involved in litigation can
be facilitated by having the referring person summarize the out-
comes desired from the consultation. In addition, a succinct
summary of the events to date should be provided to serve as a
template for review during the patient interview. Information pro-
vided by the referral source does not replace the need for a good
history; it only highlights the issues from another perspective.
The opening aspects of the history should focus on the pres-
ent illness. The examiner must not lead patients into answers by
the use of closed questions, such as Does your back pain radi-
ate to the posterior of your thigh, calf, and foot? Patients may
often answer yes to these questions even though they may not
understand what was asked or the relevance. A much better strat-
egy is to ask the patient to describe the pain. What makes the pain
better or worse? These questions can amplify the pain drawing
that is gathered before the history and physical examination.
9
This tool is helpful to maintain in the patients file to compare
over time or to establish the patients pain pattern at the time of
evaluation.
In addition, recording a few notes for later dictation, the
physician should also observe the psychologic, physical, and
emotional behavior of the patient throughout the interview
and examination. Loss of eye contact, change in voice tone,
or excessive movement on the examining table should be noted,
because these nonverbal cues may be equally or more important
than the actual words spoken. Signs suggesting a clinical depres-
sion should be noted also because depression can be commonly
encountered as both a primary and a secondary disorder in patients
complaining of low back pain. Slurred speech or an impressive
knowledge of pain medications should be noted also to provide
clues to potential alcohol or medication abuse, the latter of which
is quite common in patients who complain of chronic back
symptoms.
9,61
Pain patterns should also be noted. Does the pain intensity
stay the same throughout the 24-hour day, or is it better or worse
in the morning or in the evening? Is the pain predictable or
erratic? Is the patients sleep pattern disrupted because of night
pain? Although night pain can be associated with various forms
of malignancy or inflammatory disorders, it can also reflect clin-
ical depression or be associated with psychosocial issues.
The relationship of various activities to the pain complaints
should be discussed as well. Pain that increases with walking
short distances yet disappears rapidly with sitting or lying can rep-
resent a typical pattern in a patient with lumbar spinal stenosis.
A clinical diagnosis cannot be advanced solely on the basis of
the pain pattern, however, because of the wide variability of clin-
ical symptoms in most disorders that result in low back pain.
When interviewing a patient with low back pain that has been
present for more than 3 months, the physician should com-
pletely review the patients systemic symptoms, including fever,
chills, night sweats, weight loss, and lethargy, along with any
sources of infection, whether systemic or not, such as a localized
cutaneous abscess. Gastrointestinal symptoms are relevant
because such disorders can actually occur concomitantly with low
back symptoms and because so many patients take large doses of
salicylates or nonsteroidal antiinflammatory agents, which can
lead to significant gastrointestinal bleeding.
53
Genitourinary
symptoms are reviewed also, because bladder dysfunction can
be associated with pressure on the spinal cord or cauda equina.
Although such symptoms are more commonly related to causes
other than neural compression, an early recognition of a change
in bladder habits may signal a subtle increase in pressure on the
neural elements.
5
When genitourinary symptoms are present, the
physical examination should include a well-documented rectal
examination. A cystometrogram and a urologic consultation
may be necessary to clarify the nature of these problems.
5
Female
patients should be questioned regarding any changes in bleeding
patterns or pain related to menstruation, and those with persist-
ing back complaints should be evaluated by their gynecologists.
Medications taken by the patient should also be recorded. If the
patient has been taking multiple medications in the past for back
pain, the associated clinical response should be noted. Other back
treatment approaches, including the patients pain-free interval
after an intervention such as steroid dose packs, epidural steroid
injections, or physical therapy, should be noted as well.
Psychosocial and economic issues associated with the low back
symptoms should be reviewed. Life stressors, litigation, compen-
sation, and other secondary gain parameters would likely not have
caused the pain, but such issues can certainly maintain the
chronicity of symptoms in specific cohorts of patients. A system-
atic review of psychologic factors as predictors of chronicity
or disability highlight the limits of the available evidence,
but the roles of distress/depressive mood and, to a lesser extent,
somatization are underlined. As discussed in greater detail in
Chapter 2, the role of coping strategies and fear avoidance deserve
further research.
52,73
In recent years a list of red flags and treatment matrices have
been enlarged to include cognitive and behavioral approaches
into the early management of acute low back pain. Yellow flags
can be evaluated by means of six open questions that should be
phrased in the health care providers own words:
1. Have you had time off from work in the past with back pain?
2. What do you understand to be the cause of your back pain?
3. What are you expecting will help you?
Chapter 4c Initial evaluation of the low back region 114
4. How are your employer, coworkers, and family responding to
your back pain?
5. What are you doing to cope with back pain?
6. Do you think that you will return to work? When?
40
Moreover, blue flags (psychosocial aspects of work) and
black flags (employer-specific and global) aimed at evaluating
other socioeconomic environmental factors have been described
in the last few years.
31
The past medical history should be completed to include any
diagnostic assessments, treatment approaches not previously
noted, and doctors or others who have evaluated or treated the
patient for low back and other medical problems. The length of
any pain-free interval after previous surgical procedures should
also be documented. Short-term relief after major surgery may
occur after procedures that may not have been clearly indicated.
Other causes can include an operation performed at the wrong
spinal level, an inaccurate diagnosis, an associated medical disor-
der with referred low back symptoms, and a pain-prone patient
who tends to amplify symptoms.
A comparison of the existing occupational health guidelines
for the management of low back pain revealed that all the pub-
lished guidelines distinguished specific and nonspecific cases and
consistently recommended a clinical history to identify relevant
physical and psychosocial workplace factors and a physical
examination including neurologic screening. Red and yellow flags
are highlighted by most of the guidelines.
63
A physical examination is one among many patient expectations
72
that permits the physician to assess the patient and record the
observations. Objective findings, including deep tendon reflexes
and circumferential measurements of the calf and thigh to deter-
mine swelling or atrophy, represent the most important parameters.
Less helpful, subjective, physical examination findings include
supine straight leg raising (unless done in the sitting position as
well) and range of motion, the least reliable of all determinants.
3
Unfortunately, range of motion is still used, although to a lesser
degree, for impairment ratings as suggested in the American Medical
Association guidelines.
Inappropriate physical examination findings are important to
record also. A certain number of inappropriate physical signs have
been described and are often referred to as Waddells signs. Too
often, physicians consider the presence of three or more of these
findings as an alert that the patient may be attempting to amplify
them for secondary gain. It is important to note, however, that the
presence of inappropriate physical findings does not exclude the
presence of a pathologic process and may be due to factors other
than attempted malingering. This illness behavior may be linked
to fear of reinjury, misunderstanding of instructions, other psycho-
logic issues, and other incident issues. The onus is therefore on the
physician to recommend the appropriate diagnostic studies.
Main and Waddell
48
discussed the theoretical misunderstand-
ings of the behavioral signs in clinical practice and in the
medicolegal context. We reproduce here some of the authors
conclusions and recommendations. As behavioral responses to
examination, these signs are a form of communication between
patient and doctor. They must be understood in the context of
the patients history and offer only a psychologic screener, not
a complete psychologic assessment. Finally, they are not on their
own a test of credibility or veracity, nor are they a reason to deny
appropriate physical treatment.
48
A study showed that with regard
to return to work in patients with acute low back pain, the predic-
tive value of the nonorganic symptoms or signs (independently
or combined) was rather poor.
28
The patient should be suitably attired for the examination to
provide for privacy but also to facilitate a complete musculoskele-
tal evaluation. Together with a sheet for the supine and prone por-
tions of the examination, the standard patient gown that is open
in back is quite appropriate. The physical examination should be
complete but also age and complaint related. Although not an
essential portion of the examination in an 80-year-old patient
with back pain after a minor fall, chest expansion, for example,
is clearly important in a 20-year-old man with an insidious onset
of low back pain over a long period of time. Decreased chest
expansion (less than 2.5 cm) in such a patient could suggest the
diagnosis of ankylosing spondylitis.
A study showed that a screening system led by two physiother-
apists resulted in a clinical and economic improvement in the
care of those suffering from acute low back pain.
49
The physical
examination is divided into five components based on the posi-
tion of the patient, beginning with the patient standing.
Patient standing
The lumbar spine examination begins with the patient standing.
The physician should observe the general configuration of the
spine to detect any lateral curvatures, kyphosis, or excessive
lordosis. Patients with lumbar paraspinous spasms frequently
have a pelvic list that should be noted. In patients with lumbar
disk herniation, it has been demonstrated that although not asso-
ciated with the location of nerve root compression, the direction
of lumbosacral scoliotic list is related to the side of disk hernia-
tion.
64
In young adult males with low back pain, chest expansion
should be measured with a cloth tape because expansion less
than 2.5 cm suggests an inflammatory process such as ankylosing
spondylitis.
After observing the spine orientation in the erect patient, the
physician should ask him or her to flex forward, a step particu-
larly important in adolescents to detect early lateral curvatures of
the spine. To assess the range of motion of the lumbosacral
spine, the physician should stand behind the patient and observe
the lumbar paraspinous muscles. Any eccentric contractions of
the musculature suggest lumbosacral paraspinous spasms; limited
motion without evidence of such eccentric contractions might
suggest a lack of patient cooperation even though there are other
possibilities (such as a congenital block or previous fusion).
Forward and lateral flexion and extension of the lumbar spine
should be observed. Normal patients should be able to bend
forward nearly to touch their toes and to the sides to touch the
fibular heads, but extension of the spine is extremely variable.
In general, pain increased by flexion suggests lumbar disk abnor-
malities and pain with extension suggests degenerative changes
involving posterior elements of the spine, lumbar spinal stenosis,
or both. Occasionally, patients with lumbosacral paraspinous
spasm can flex forward reasonably normally but have difficulty
returning to the erect position. Such patients may accomplish this
move in a two-phase recovery by flexing the knees and extending
the hips without motion in the lower back.
The true value and reliability of flexibility assessment is, how-
ever, dubious. The reliability of lumbar flexion and extension
measured with an electronic inclinometer within a complete phys-
ical examination was evaluated in a group of normal volunteers.
The intrarater and interrater reliability for flexion were, respec-
tively, 0.48 and 0.56, whereas the same values for extension were
0.53 and 0.37, respectively.
33
In older patients, the range of motion
of the cervical spine should also be assessed because degenerative
osteoarthritis of the cervical spine occasionally results in low back
complaints. A study including 27 patients suffering from lower
back pain and unilateral single nerve root symptoms, 14 patients
with multilevel nerve root symptoms, and 10 control subjects
showed that low back pain correlated significantly with restriction
of anteroposterior spinal flexion measured with a computerized
triaxial potentiometric analysis system.
54
After observing the range of motion, the physician should
percuss the spine to detect any localized tenderness, a subjective
reaction. This test has little value if the patient has tenderness at
multiple areas, but consistent localized tenderness over the mid-
line of the spine may suggest inflammatory diskitis (or fractures,
tumors, and so forth). The costovertebral angle should be palpated;
tenderness in this area suggests a genitourinary problem such as
pyelonephritis.
Patients should next be asked to walk on their heels and then
toes to assess the overall strength of the dorsiflexors (L5) and
plantar flexors (S1) of the ankle. In particular, the extensor hallucis
longus muscles should be observed when the patient is walking on
the heels, because discrepancies can be detected between this act
of walking and later passive strength testing. To assess and detect
weakness of the triceps surae muscles, which are innervated
primarily through the S1 nerve root, the physician should ask
the patient to hop several times on the left foot, then on the
right foot, and note any discrepancies in the two abilities.
The patient should be observed also while walking in the
examining room. Extreme staggering from side to side and other
bizarre gait patterns suggest symptom amplification. Patients with
true herniated disks often have a gait pattern slightly antalgic on
one side but with no bizarre abnormalities.
Patient sitting
The patient should next sit on the edge of the examining table
so the physician can perform the knee and ankle reflex tests and
determine the strength of the extensor hallucis longus muscle.
This latter examination is critical in all patients complaining of
back and leg pain because many have weakness of the extensor
hallucis longus but not the tibialis anterior. Weakness of the
extensor hallucis longus in a patient who complains of back and
leg pain suggests involvement of the L5 nerve root. The extensor
digitorum brevis muscle should be checked; however, some
authors remain unconvinced that observation of this muscle has
any diagnostic significance in patients with lumbar disk disease.
Asymmetry is often observed in patients who have never had low
back and/or leg pain.
Figure 4c.1 Sitting straight leg raise test. The patient leans back in
the tripod sign, indicative of true sciatic tension.
The most important portion of the sitting examination is the
distracting straight leg raise (SLR) test (Fig. 4c.1). The SLR test
has shown to be adequate in healthy subjects when performed
within a complete physical examination.
33
During this lifting of
an extended symptomatic leg in the sitting position, patients
with herniated disks and true symptoms of sciatic tension arch
backward and complain of pain in the buttock, posterior of the
thigh, and calf. Patients who do not have true sciatic tension do
not recognize this as a sciatic tension test and therefore have no
symptoms. For the patient who complains of pain in the neck
as well as the lower back, the strength and reflexes of the upper
extremities can be evaluated while he or she is sitting.
Patient supine
With the patient supine on the examining table, the physician
uses a standard tape to measure the true length of the limbs from
the anterior superior spine to the medial malleolus on both sides.
Although significant discrepancies (more than 2.5 cm) in limb
lengths can result in mild compensatory scoliosis and low back
discomfort, these associations are uncommon.
The physician should observe the thigh and leg muscles for
early signs of atrophy. In addition, the physician should use a
cloth tape to measure the circumferences of both thighs one
handbreadth above the patella and those of both calves one
handbreadth below the patella. Discrepancies greater than 2 cm
again are probably significant and suggest muscle atrophy.
For the standard ipsilateral SLR maneuver, the physician stands
to the patients right, places the left hand on the patients patella
to extend the knee, places the right hand under the os calcis, and
then lifts the leg while keeping the knee extended (Fig. 4c.2).
Because patients often describe their discomfort in different
locations in the extremity, the objectivity of the test results
are qualified. If the patient complains of radicular discomfort
during the test, the limb should not be lifted any higher. At that
moment, plantar flexion of the ankle should be performed as a
distracting test. Because plantar flexion of the ankle should not
increase back pain, exacerbation of pain may suggest amplifica-
tion of symptoms by the patient. Dorsal flexion, on the contrary,
should increase sciatic tension and pain (Fig 4c.3).
The physician should perform the crossed SLR test also by
lifting the nonsymptomatic extremity as in the ipsilateral SLR
test. If the patient complains of discomfort radiating into the
symptomatic extremity when the well extremity is lifted, this test
is positive, almost invariably indicating lumbar disk herniation.
During both the SLR test and the crossed SLR test, the patient
must be allowed to state where the discomfort is occurring.
Specifically, asking the patient whether lifting the well extremity
causes pain in the symptomatic extremity invalidates the test.
It is important to note that in patients with L4-L5 and L5-S1
disk herniations, the SLR test has very high sensitivity (95%) but
lower specificity, whereas the cross SLR has much lower sensitiv-
ity (25%) but significantly higher specificity (90%).
20
Figure 4c.2 Supine straight leg raise (SLR) test. For maximum
accuracy in identifying sciatic tension, this test must be compared with
the sitting SLR test.
Patricks test should then be performed bilaterally. In this test,
the shear force applied across the sacroiliac joint helps detect
early abnormalities. Many patients with osteoarthritis of the hip
complain of buttock pain rather than the classic groin discomfort,
causing the hip joint often to be overlooked because of the
apparent back problem. Patients with abnormalities of the hip
joint cannot tolerate Patricks test, however, because of the
discomfort when the limb is fully externally rotated into the
abducted position. While the patient is supine with the limbs
extended, the physician should therefore gently rotate the lower
extremity both internally and externally, a gradual rotation that
reveals early irritability in the hip joint. If internal and external
rotations cause pain, it may arise from that area. Brown et al
14
reported on the clinical signs that may be helpful to distinguish
between a hip disease and a spinal origin of pain: the presence
of a limp, groin pain, and limited internal rotation of the hips
more often was associated with and predictive of a hip disorder
than a spine disorder.
The abdomen should be examined by palpating the four quad-
rants to detect any intraabdominal masses. Abdominal lesions
may erode into the lumbosacral plexus and cause symptoms iden-
tical to those of lumbar spinal stenosis or disk disease (Fig. 4c.4).
The strength of the abdominal muscles should be assessed by
having the patient flex the knees while keeping the feet flat on
the table and then perform a sit-up. Patients who have extreme
difficulty completing even one sit-up are theoretically excellent
candidates for a vigorous rehabilitation program. In addition, the
patient should be asked to hold the lower extremities 15 to 20 cm
off the table. In general, a patient with an established herniated
disk can easily perform this maneuver, so the primary value of this
test is to assess the strength of the abdominal musculature rather
than determine the likelihood of a disk herniation.
With the patient supine, the motor strength of the iliopsoas,
quadriceps, and hamstrings, along with Babinskis reflexes and
proprioception, should all be assessed. A sensory examination
also should be performed and recorded.
A study demonstrated significant elevations of warm, cool, and
touch perception thresholds correlated with leg pain in patients
with unilateral L5 or S1 nerve root pain. However, dermatomal
quantitative sensory tests require some specific tools that are not
part of the routine clinical equipment.
54
Patient on side
The supine patient is then asked to turn on one side and to raise
and maintain the superior extremity against resistance by the
physician (Fig. 4c. 5). In most patients, the gluteus medius is inner-
vated primarily by L5, so patients with L5 radiculopathy often
have weak abductors, as do patients with significant hip disease.
The trochanter should be palpated to test for trochanteric bursitis.
These same tests should be repeated with the patient lying on the
opposite side.
With the patient on one side, perianal sensation and but-tocks
sensation also should be evaluated. All patients over the age of
40 and any patient suspected of a neurologic deficit should have
a rectal examination. In males, anal sphincter tone and the size
of the prostate may be assessed. Female patients with chronic
back pain should have a pelvic examination by a gynecologist.
Figure 4c.3 Dorsiflexion of the ankle during a straight leg raise test
increases pain.
B A
Figure 4c.4 (A) CT of a calcified arthrosynovial cyst (circled) causing left nerve root entrapment. (B) The same pathology is less obvious
on an MRI.
Figure 4c.5 Gluteus medurs strength testing with the patient on the side and abducting against resistance.
Patient prone
With the patient prone on the examining table, the lumbar
spine, sacrum, and sacroiliac joints should then be reexamined
for any localized tenderness. A reverse SLR maneuver can easily
be accomplished by the physician simply by lifting both of
the patients lower extremities off the table, although quite
often just bending the knees in the prone position is enough
to elicit pain in the L3 or L4 dermatome. The patient should
next flex the knees 90 degrees so that the physician can observe
internal and external rotation of the hips. In most patients,
the amount of internal and external rotation is quite similar.
Patients with femoral anteversion, however, have excessive
internal rotation and limited external rotation and often
experience discomfort in the low back area and buttocks
while running. When the patient is prone, ankle jerks often are
easier to reexamine and compare; the absence of one or both
reflexes should be noted. Finally, the patient should extend first
one lower extremity and then the other by using the gluteus
maximus muscle. Increased low back discomfort during this
maneuver suggests a more superficial myofascial source of the
symptoms.
ADDITIONAL INVESTIGATIONS
After careful history taking and physical examination (and only
then), a number of technical examinations can be ordered based
on the results. None of those examinations should be considered
as a screening tool, to see how they come out. A specificity of
low back pain is that in most cases a precise cause of nociceptor
cannot be precisely determined despite the increasing sophistica-
tion of investigations.
Specialized examinations should serve to confirm or pinpoint
a suspected diagnosis, and the precision of each should be known.
That precision can be determined by statistical measures of sen-
sitivity (the proportion of subjects with the disease in whom the
examination is positive), the specificity (the proportion of sub-
jects without the disease in whom the examination is negative),
the accuracy, and the predictive value. The two latter measures
are not always available in all cases, and in the context of back
pain the specificity of imaging is often poor due to a wide range
of abnormal images that are asymptomatic. With more sophisti-
cated examinations, more asymptomatic abnormal images are
found. In contrast to severe osteoarthritis of the hip or knee,
which does not affect everyone and is seldom asymptomatic,
marked degenerative changes in the spine seem to affect nearly
all human beings with aging and are often asymptomatic.
The patient should be told the reason for which an examina-
tion is ordered and advised that it may show some meaningless
pathologic images that are irrelevant to the present symptoms.
Those incidental findings are usually nonsignificant and not what
was suspected and researched. We all see patients coming with
multiple radiology reports where statements about black disk,
bulging disk, or degenerative changes have been strongly
underlined or highlighted by the patient (or sometimes the doctor).
Those misconceptions can lead patients to further impressions of
seriousness and prolonged disability. Early and complex imaging
with precise description of nonsignificant abnormalities facili-
tates the medicalization of low back pain,
12
and duration of
disability is associated with its early increased use.
47
Patients perceptions, expectations, and demands play a major
role in the use of imaging modalities to diagnose low back pain.
A myth common among patients is that radiographs will show
the exact cause of their back pain,
36
so they expect to have radi-
ographs when seeing doctors for such complaints.
43
They wish to
have an x-ray examination ordered, moreover, and physicians
attitudes are often correlated to patient wishes.
77
It appears then that patient education is necessary, although
physician education is perhaps even more acutely needed.
74
Although many guidelines about diagnostic procedures in back
pain have been published in several countries, multiple studies
show that most are not followed in the United States,
27,56
Canada,
8
Norway,
77
and Spain.
29
All those studies reveal that physicians,
mainly in primary care settings but also specialists, still order too
many examinations that are of little use.
Plain radiograph
Plain radiographs have been the standard (and only widely
available) imaging technique in assessment of back pain for
decades. They show the bony structures precisely, displaying
spondylolysis, spondylolisthesis, deformities, tumors, fractures,
and degenerative changes such as disk narrowing, disk vacuum,
and traction osteophytes. The latter, however, appear to be a nor-
mal evolution of the spine and are very common in symptom-free
middle-aged and aged subjects. Instability can be assessed on
dynamic (flexion/extension/lateral flexion) radiographs, but the
relation of radiologic instability to back pain is subject to
discussion.
65
For these reasons plain films have very low specificity
and therefore low diagnostic precision
38
and make no difference to
the outcome for back pain,
78
especially in elderly subjects.
10,71
In the case of acute low back pain in a subject between 18 and
50 years of age, plain films are indicated only if there is a history
of trauma, malignant disease, or symptoms of infection. In the
case of neurologic symptoms, magnetic resonance imaging (MRI)
(or computed tomography [CT] if it is unavailable) might be a bet-
ter diagnostic tool. If no clinical improvement is observed after
6 weeks, plain films may be taken to help exclude a diagnosis of
tumor, infection, spondylolysis or olisthesis, and osteoarthritis of
the hip, and along with simple laboratory tests will rule out sys-
temic diseases.
37
Some studies suggest, however, that in the
absence of red flags, radiographs should not be ordered even after
6 weeks of symptoms.
41
In chronic low back pain, the same
pathologies should be ruled out, but preferably by MRI.
10
Myelography
Until the advent of CT, myelography was the only examination
that enabled physicians to assess spinal neural structures, the dural
sac, and the roots. Myelography is still the only widely available
examination permitting a dynamic view of the dural sac during
flexion and extension in the upright posture (Fig. 4c.6). Given the
decrease of the dural sac diameter during extension, some cases of
Chapter 4c Additional investigations 119
stenosis can be underestimated during examinations like CT or
MRI that are performed in a supine position. Although upright
MRI is becoming available, it is very expensive, uncommon, and
constrained in patient positioning and acquisition time, making it
inappropriate for this kind of assessment in stenotic patients.
Upright myelography examination appears useful also in
the diagnosis of position-related disk herniations
35
and those
in the lateral recess where MRI may underestimate root compres-
sion in nearly 30% of cases.
2
Indeed, some authors have demon-
strated similar sensitivity and specificity in myelography
and MRI.
55
Myelography is an invasive procedure, however, and neuro-
logic or infectious complications, although very rare, are possible.
Combined with CT (myelo-CT), myelography still has a place in
cases of strong clinical suspicion of stenosis or herniated disk not
clearly demonstrated on other imaging modalities. It also enables
the laboratory analysis of the cerebrospinal fluid to be performed
to rule out a number of neurologic diseases.
Computed tomography
CT is the first examination to provide axial and three-dimensional
representations of the spine and the first noninvasive examination
to provide a view of spinal neural structures. When it appeared in
the 1970s, it was a true revolution. It has now been widely replaced
by MRI for the assessment of neural structures but still remains
the best examination for the visualization of bony elements. It is
also the only examination available for claustrophobic patients or
for those with pacemakers or ferrous metallic implants. CT also
offers more precise views of calcified disk protrusions.
24
B A
Figure 4c.7 (A and B) Spondylolysis and olisthesis are best investigated by computed tomography. In this case the pars defect is partially filled
by Gills nodules (ossified fibrous tissue), which when associated with a disk bulge provoke a lateral stenosis.
Figure 4c.6 Myelogram showing multiple level central degenerative
stenosis (arrows). Myelogram remains the only widely available
examination enabling dynamic and upright assessment.
CT shows more precisely the patterns of fractures in trauma
cases and investigates pars fracture in spondylolysis or olisthesis
(Fig. 4c.7). In the case of spinal stenosis, if MRI allows a better
view of neural elements, CT is still invaluable to investigate the
osseous participation in the stenotic process. We believe that it
complements MRI before surgical treatment of lumbar stenosis.
Spiraled helical CT allows a three-dimensional view of long
spinal segments and as such may be very interesting for the accu-
rate description of deformities.
Magnetic resonance imaging
MRI has become the standard investigation tool for spinal disor-
ders. The precision of this examination handicaps its specificity,
however, because it demonstrates a high frequency of clinically
irrelevant abnormal images without associated symptoms. Some
studies have shown a prevalence of 28% of disk herniations, at
an average age of 42, in asymptomatic subjects,
11,39
up to 52% of
which presented at least one bulging disk.
39
With MRI, degener-
ative intervertebral disk disease is present in one third of subjects
between 20 and 39, over half of those between 40 and 59, and in
nearly all subjects over that age.
11
Apparently, a normal physio-
logic evolution of the decrease of disk hydrophilic properties, dark
or black disks, appear in almost everyone. These findings under-
line that to avoid misunderstandings by patients, MRI results
must be interpreted with great care and meticulously related to
clinical presentation. Even in the presence of symptoms, the cor-
relation between the severity of clinical findings and MR images
of mild to moderate compression due to bulging or stenosis
is poor.
4
Keeping these limitations in mind, MRI is nevertheless the best
tool to investigate compromise of neural elements of the spine.
In spinal stenosis it is especially useful in determining the extent
of the narrow canal. In presence of a suspicion of neural compres-
sion, the addition of MR-myelography, realized through specific
acquisition sequences, complements the results of the standard
MRI in many cases (Fig. 4c. 8,9).
26
Chapter 4c Additional investigations
Figure 4c.8 Voluminous extruded disk herniation provoking a cauda
equine syndrome. In this case magnetic resonance imaging is the
examination of choice. The patient had a full recovery after surgery.
Figure 4c.9 Magnetic resonance image of a lytic spondylolisthesis
showing root entrapment in the foramen. The root (A) is hampered by
the disk bulge in the foramen (B) consecutive to the sliding and
flattening of the disk.
121
Because it is usually performed in the supine position, MRI
may underestimate images of compression in position-related
stenosis or sciatica, as is the case with neurogenic claudication.
Devices enabling axial compression during supine MRI (or CT)
appear to add useful information about the decrease of the
spinal canal diameter that appears during upright weight-bearing
positions
76
and also to enable more precise surgical strategies to
be performed.
32
MRI is highly specific and sensitive also in the
research of malignant and infectious spinal diseases, warranting the
use of gadolinium-enhanced MRI in acute low back pain when one
of those pathologies is suspected.
30
The results in MRI investigation of back pain are more subject
to caution. An example is the high intensity zone, the presence
of which has appeared to show much promise as a marker of
discogenic low back pain. The high intensity zone is a high T2
signal in the posterior and/or posterolateral annulus that seems
to increase during axial loading.
59
Some authors have found a
high correlation of this finding with pain and annular penetration
of the dye during diskography, which they believe demonstrates
a very high positive predictive value.
1,60
Other authors, however,
have shown a high prevalence of high intensity zone in asymp-
tomatic subjects,
15
whose reaction to diskography is similar to
that of symptomatic patients.
20
The sensitivity of the sign is low,
58
and although it seems that the high intensity zone may show an
annular fissure, that fissure is not a reliable sign of painful disk
disease. In patients without active symptoms, furthermore, annular
disruption is a weaker predictor of future low back pain than
psychologic distress.
19
Radionuclide bone scan
Radionuclide bone scan (isotopic) is a highly sensitive but
poorly specific examination. Of the different radionuclides that
can be used, technetium-99m is the most common in spinal indi-
cations because it is highly sensitive for malignant diseases and
infections. Bone scans using markers such as gallium or marked
leucocytes show better specificity for infections.
Nearly 40% of subjects with spinal metastasis and normal plain
films have a positive bone scan.
50
The test might help also to deter-
mine whether a vertebral or pelvic fracture is recent or old.
Single photon emission CT has been suggested as useful for
identifying patients with facet joint disease more likely to benefit
from facet injections.
23
Single photon emission CT also reveals
many abnormalities not detected on a standard radiograph,
57
but
here again one might wonder about the clinical relevance of those
findings.
Whereas either the planar bone scan or single photon emis-
sion CT reveals areas of increased bone turnover, these tests lack
the specificity necessary to determine the true nature of the
lesion and serve only as indicators for further studies in accor-
dance with the clinical presentation.
Ultrasonography
Ultrasonograms may be useful in cases of paraspinal soft tissue
infections or tumors or to rule out other sources of lumbar pain,
such as urinary tract calculus or kidney diseases. Some studies
have proposed ultrasonic imaging combined with pain provoca-
tion by vibrations to diagnose internal annular tears,
79
but this
technique has not gained widespread acceptance. Investigation
of nerve roots and facets has been abandoned due to the lack of
accuracy.
51
Those examinations do not play a major role in spinal
imaging.
Diskography
Provocative diskography, which aims at back pain reproduction,
has been a controversial subject for many years. It has been con-
sidered by some authors to be the best indicator of discogenic
pain and has been widely used to confirm surgical indications of
fusion and, more recently, disk replacement. Even after positive
diskography, however, fusion results remain unpredictable.
75
Furthermore, the frequency of positive responses to diskography
among asymptomatic subjects challenges the value of this examina-
tion as a predictor of clinically relevant discogenic pathology.
16,18
Although diskography is indeed a good indicator of annular
tears, the latter do not appear to predict a clinically relevant
spinal pathology.
16
Specificity of diskography appears low,
17
and
pain intensity during injection is influenced strongly by the
patients psychologic factors and compensation claims.
16
In any
case, diskography has no place in the initial assessment of low back
troubles.
Electromyography
Electromyography may be useful in specifying the level of symp-
tomatic compression and ruling out peripheral neuropathies
(diabetic, ethylic, or other). One must bear in mind that elec-
tromyography shows abnormal signals only several weeks after
the occurrence of a nerve compression. Although interesting as
an adjunct examination, electromyography is not an essential
tool in the initial assessment of spinal troubles.
Mechanical testing
The inability to correlate low back pain to anatomic findings and
the difficulties in quantifying pain have directed much effort
toward measurement of spinal performance through the assess-
ment of function across various dimensions such as flexibility,
strength, speed, endurance, and coordination. Goniometers and
isokinetic and isoinertial dynamometric devices are currently
used. Isoinertial testing seems to be the most physiologic and
clinically relevant approach. Useful for prescribing muscle-
strengthening therapy precisely, it enables the physician to follow
up on the patients progress and can also be used to assess the effi-
cacy of diverse treatments.
44,46,68
In certain pathologies like spinal
stenosis, specific patterns of motion have been demonstrated,
69
and early decrease of spinal function has been shown in subjects
with Parkinson disease.
13
The use of neural network technique
analysis of motion patterns has enabled researchers satisfactorily
to assign back pain patients to pathologic categories based on the
Quebec Task Force classification.
7
These tests can also provide
insight into the maximum effort exerted by the subjects
62,66
but
despite the hopes of their proponents are by no means back pain
lie detectors.
The measure of flexibility is of limited value in the assessment
of the spine,
70
and the current American Medical Association
guidelines for evaluating disability, heavily based on spinal range
of motion, can lead to irrelevant results.
45
More elaborate proto-
cols, based on more complex analysis of kinematic profiles, appear
to be much more promising.
25
Other diagnostic studies
Laboratory evaluation should be recommended for patients
who are not responding to treatment or who have severe pain.
Although many of these tests are indicated in specific situations,
a useful screening evaluation for patients with persistent symp-
toms should include a complete blood count, sedimentation
rate, coagulation survey, sequential multiple analysis-18, and
urinalysis. Patients who show diminished bone density should
be evaluated more thoroughly with thyroid studies, protein
electrophoresis, urinary calcium, and evaluation of parathyroid
hormone levels. Should one proceed this far in the evaluation,
a referral to an endocrinologist with an interest in calcium metab-
olism is clearly warranted. In young male patients suspected
of having ankylosing spondylitis, an HLA-27 antigen study can
be ordered.
DIFFERENTIAL DIAGNOSES
When evaluating patients with complaints of low back pain, the
physician must remain vigilant to identify those whose symptoms
result from referred pain unas-
sociated with the intervertebral
disk or spinal nerves. In this
time of intense focus on cost,
the physician must also remain
dedicated to a proper evalua-
tion for the patient and not
succumb to managed-care
bureaucrats who are interested
primarily in the cost rather
than the quality of care.
Patients with low back pain
represent an interesting group.
A list of differential diagnoses
is provided in the box to the
right. Approximately 2% of
patients who come to a low back
specialty clinic have evidence
for neoplasms as the source of the symptoms.
10
A list of sus-
pected causes coupled with the knowledge of appropriate testing
aid the physician in formulating a proper workup.
A complete history and careful physical examination must
underlie any assessment for low back pain. Physicians should
remember that their most effective and readily available tools are
their hands and brains. Only after this meticulous first stage has
been completed can specialized examinations be ordered to answer
precise questions and to confirm or eliminate specific pathologies.
Evidence-based medicine principles apply to diagnostic investi-
gations, but there are no screening tests for back pathologies.
The poor specificity of the most common imaging techniques is
inversely proportional to the frequency of their use. Radiographs
and now MRI, which seem to be used almost as routine investiga-
tions in low back pain patients, provide a huge quantity of clini-
cally irrelevant information. In a world in which health care
resources are decreasing while the population ages and increasing
technology costs demand further funding, physicians will be held
accountable for unjustified practice costs. Patients should be edu-
cated and alerted that technology will not invariably uncover the
precise reason of their pain, but physicians too require education,
as the failed implementation of many guidelines painfully shows.
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Treatment Options
Margareta Nordin, Federico Balagu, and Christine Cedraschi
More than 17 guidelines drawn from large evidence-based
systematic literature reviews have been published in different
countries on low back pain (LBP),
8,79,96
a topic that the World
Health Organization included in their report, the Bone and Joint
Decade 2000-2010.
38,59,98
LBP remains a common affliction that is debilitating for
the patient and expensive for the working individual and for
society.
31,70
This chapter gives an overview of treatment modali-
ties for returning an individual to work during the course of
acute to chronic LBP. The focus is on LBP that is nonspecific,
where causality cannot be established and which is treated by
a structured evidence-based approach to prevent disability and
chronicity.
SPECIFIC AND NONSPECIFIC LBP
The classification for pain in the lumbar spine used by clinicians
is specific or nonspecific, depending on which of more than
60 diagnoses applies.
Specific low back pain
The common feature for specific low back pain (SLBP), the diagno-
sis in up to 2% of all early back pain cases, is a causal link between
a structural pathology and the described experience of the patient
(see Chapter 4c). SLBP may result from systemic disease, infection,
injury, trauma, cauda equine, or structural deformity. Additionally,
nerve root pain, which occurs in about 5% of the individuals
seeking care early, includes diagnoses such as a disk prolapse or
spinal stenosis. These conditions are treated with or without
surgery and should be referred to a specialist for determination
of care.
6,8,57
Nonspecific low back pain
Nonspecific low back pain (NSLBP), which afflicts 85-90% of all
individuals seeking care, is a diagnosis of exclusion: No precise
structure is identified as the cause. NSLBP is attributable to
common diagnoses such as lumbago, myofascial syndromes,
muscle spasms, mechanical LBP, back sprain, and back strain.
These conditions all include pain in the lumbar region that may or
may not radiate to one or both thighs but not below the knee(s).
The following International Classification of Diseases diagnostic
codes are suggested to best represent NSLBP: lumbago (724.2) and
sprains of the lumbosacral region (846.0-3/8-9, 847.2-3).
24
C HA P T E R
4d
TREATMENT MODELS
Two treatment models are commonly used in treating back
pain: the medical model and the biopsychosocial model. Modern
medicine uses the classic scheme, which implies that an interac-
tion between the patient and an exposure leads to an illness
complex.
99
This model works well in dealing with SLBP. The pro-
cedures are to
1. Recognize patterns of symptoms and signs by history and
examination;
2. Identify underlying injury or disease by investigation and
diagnosis;
3. Treat underlying injury or disease by specific intervention;
4. Expect the patient to recover.
Preferably applied to NSLBP, the biopsychosocial model identi-
fies factors associated with delayed recovery for return to activity
and, most often, return to work. The model calls for identification
of symptoms and signs outside the traditional medical field
such as beliefs, high perception of disability, kinesophobia,
depression, stress, job dissatisfaction, anxiety, somatization, or
lack of control.
22,94
These contributing factors are treated with nontraditional
medical approaches such as cognitive behavioral therapy (CBT)
or ergonomic or occupational intervention. The biopsychosocial
model in occupational health care helps to
1. Recognize the nonspecific nature of the back pain;
2. Identify underlying psychosocial and/or environmental
factors;
3. Treat these factors with appropriate interventions;
4. Empower the patient to assume responsibility for managing a
condition with possibly frequent recurrence.
The first occupational health guidelines for the management of
LBP at work were published in 2001 (see also www.facoccmed.
ac.uk).
96
These guidelines are based on an extensive systematic
review of the scientific literature primarily in terms of occupational
settings or outcomes.
PATIENT EXPECTATIONS
A patient approaches a physician with expectations and precon-
ceptions. The patient expects diagnostic explanation, pain relief,
referral for treatment, instructions for coping with pain and
disability, and, in an occupational environment, help with sickness
certification or light duty assignment. Some patients expect
imaging or special tests and specific medication. In one cross-sec-
tional study (n = 1942), for example, 77% of the responders
believed that if back pain exists, a wrong movement could lead to
a serious problem. Forty percent believed also that radiographs
and imaging could always identify the cause of back pain.
40
It takes time to explain inappropriate concepts and expectations.
The first encounter addresses such misconceptions, whereas at
subsequent visits the important concepts for recovery are dis-
cussed and reinforced.
69,91
Evidence-based information educates
the patient that selective treatments may take time; some treat-
ments may pose higher risks, and the effects of new treatments
are not entirely known. The patient and clinician discuss the pro-
posed treatment and the prospect of harm when work is resumed
and agree on a regimen including compliance and return to work.
Patient education about treatment choice and expected outcome
is a key factor for success.
49,97
NATURAL HISTORY AND RECURRENCE
OF NSLBP
Acute NSLBP has a favorable prognosis. Some authors argue
that NSLBP is a lifetime disease if recovery has not occurred
during the first 3 months,
10,84,92
as is true for a large subgroup of
individuals.
48
Von Korff et al
93
found that 20% of the U.S. pop-
ulation suffers from chronic LBP each year and that about 30%
of them suffer chronic pain over their lifetimes.
Studies focusing on the natural history of LBP report that
80% of patients who consult a health care provider for acute
NSLBP can expect to resume normal activities within 4 to
6 weeks. By 12 weeks, the rate of recovery rises to almost 90%.
Compared with approximately 35% to 40% of patients with
SLBP, 10% or fewer of NSLBP patients experience chronic pain
and work incapacity.
1,11,70
The recurrence rate in NSLBP varies considerably from 5% to
70%, with up to 2 years follow-up in studies of both general and
specific occupational populations.
18,92
Recurrence or episode rate
is difficult to estimate, however, because the definition of an
episode is not standardized in different studies.
29
We diagnose
recurrent NSLBP when the employee has returned to regular
work pain free for at least 8 weeks since the previous episode.
71
DURATION OF PAIN AND TREATMENT GOALS
The following definitions of LBP and duration since onset are
used and well accepted: The duration of acute NSLBP is 0-4 weeks
and that of subacute NSLBP is 4-12 weeks.
1,8,33
Although episode
definition is not standardized, intermittent or recurrent NSLBP
is diagnosed when the patient is pain free or almost pain free
between the bouts of pain.
1
Chronic NSLBP is defined as a dura-
tion of pain longer than 12 weeks.
1,8,17,33
The most important goal for acute LBP is a continuum of occu-
pational care and identification of factors to prevent chronicity
during the first 3 months after the patient seeks help. Management
in occupational medicine can make a difference by providing
regular follow-up and using a multidisciplinary approach to rein-
force return to work with temporary job accommodations or, in
some cases, job change.
ACUTE NSLBP AND EVIDENCE
FOR TREATMENT
Because acute NSLBP is largely self-limiting, minimal or no med-
ical interventions are recommended for most patients.
1,26,33,67,88,95
The most important message is for the patient to keep as active
as tolerable without bed rest.
1,33,67,73,74,88
Specific exercises are not needed and may also have a nega-
tive effect. In two systematic reviews and a recent meta-analysis
on exercises and NSLBP, the authors concluded that exercise
therapy is as effective as either no treatment or other conservative
treatments in 11 trials involving 1192 adults.
1,45,88
A series of five to six manipulations in the acute stage of
NSLBP reduces pain and disability for up to almost 3 weeks.
4,8,14,33
Alternatively, the patient may have a short course in pain man-
agement involving five to six encounters with a therapist trained
in the biopsychosocial approach.
61
In a comparison of manipulation and pain management
in patients with acute NSLBP, the outcomes at 3 months and
12 months were almost identical (difference 0 [95% confidence
interval (CI), -1.3-1.4]), with a decrease in disability score of
about 8.8/24 points.
44
With the patient maintaining tolerable
activity, manipulations and pain management in acute NSLBP
are superior to all passive modalities (mobilization, diathermy,
massage, heat) over the long term.
21,33
Continued passive long-
term treatment of NSLBP is harmful because it precludes patient
involvement, increases fear that the condition is serious,
decreases cardiovascular conditioning, and reinforces the role
of sick person.
94
For the employee seeking care, the message is sometimes dif-
ficult to understand, particularly if the injury or back pain started
at work. Why should I go back to work, where I was injured, if
it may hurt my back? he or she asks. This legitimate question
needs to be answered in relation to the type of job involved and
the availability of modified work for a limited period if neces-
sary. The occupational health care provider is best placed
to answer this question and to adapt the employees duties if
necessary.
Self-care for acute NSLBP
Self-care implies that the NSLBP patient can control symptoms
and engage in behaviors necessary to reduce or alleviate them.
Playing an active role in recovery, the patient decides what
behaviors are tolerable. The message to remain as active as pos-
sible cannot be overemphasized.
1,88
Self-care techniques include
(but are not limited to) stretching and/or walking or using heat
and/or ice or relaxation techniques
72
when convenient for short-
term relief.
Written evidence-based information is helpful to reinforce
the good prognosis of NSLBP, explaining the biopsychosocial fac-
tors influencing recovery and offering instructions for self-care.
16
Company-specific information may have a better impact than a
generic pamphlet.
46,75
In summary, systematic literature reviews, randomized con-
trolled trials, and meta-analysis of acute NSLBP show that self-
care in the form of maintained activity, education, and
medication as needed is as effective as manipulation or a short
course of pain management based on the biopsychosocial
model. Bed rest and passive treatment should be avoided. If
patients demand treatment, it is prudent to ask about their
expectations and goals, educate them, and reinforce the positive
prognosis. The natural history of acute NSLBP measured as
return to work is altered only marginally by prescribed treatment
at this early stage, but together with self-care it provides short-
term relief from pain. Patients should be followed until they
resume work.
Chapter 4d Treatment options 126
INTERVENTIONS FOR SUBACUTE NSLBP
The interval of 4-12 weeks in the management of NSLBP has
been called the window of opportunity. The occupational
health care professional can become instrumental in preventing
work disability and recommending alternative and more inten-
sive regimens of evidence-based treatment. A clinical reevalua-
tion at 4 weeks includes a careful orthopedic and neurologic
examination along with imaging and other diagnostics if war-
ranted to exclude any ongoing process in the spine.
8,33
If the
diagnosis remains NSLBP, screening for psychosocial factors is
warranted.
Yellow flags
Yellow flags
56
indicate psychosocial barriers to recovery and pre-
dict poor outcomes related to occupational health care because
the patient does not return to any kind of work.
55
Yellow flags are
employee misconceptions (that back pain is harmful or can be
severely disabling), avoidance of movement or activity due to
fear of pain, tendency toward depression, withdrawal from social
interaction, or expectation of continued passive treatment rather
than belief that active participation will help.
55,61
Six open-ended questions are helpful for revealing yellow
flags:
1. Have you had time off work in the past with back pain?
2. What do you understand to be the cause of your back
pain?
3. What do you expect will help you?
4. How is your employer responding to your back pain? Your
coworkers? Your family?
5. What are you doing to cope with your back pain?
6. Do you believe you will return to work? When?
Chapter 4d Interventions for subacute NSLBP 127
In one study from a primary care cohort (n = 800) over 5 years,
not recognizing psychosocial issues early on has been shown
to account for an increase of 10 consultations per year per
patient.
52
Blue flags
In occupational health care it is also helpful to recognize so-called
blue flags that are related to possible work problems. Initially
proposed by Main and coworkers,
7,65,66
blue flags represent occu-
pationally related predisposing factors for delayed recovery and
return to work. Blue flags include factors such as fear of losing
ones job, monotony at work, lack of job satisfaction, and poor
relationships with peers and supervisors. Occupational health
care professionals are particularly well placed to address these
issues. Appropriate intervention such as CBT aims to strengthen
the employees coping skills and problem solving. In collaboration
with the occupational physician, a discussion with supervisors or
a workplace visit can occur early in the course of back pain to
prevent chronicity. An active approach combining patient partic-
ipation with involvement by the health care provider, the man-
agement, and the union is beneficial.
60,62,81
Management of NSLBP
The management of subacute NSLBP treatment should proceed
in a stepwise fashion from least to the most invasive treatment
(Fig. 4d.1). There is weak to moderate evidence in randomized
controlled trials for efficacy of a treatment regimen including
exercise, behavioral therapy, and ergonomic intervention.
33,70
The employee must be convinced to participate actively to pre-
vent long-term chronicity and disability. Meaningful outcomes for
the patient that need to be discussed are those of taking control of
Convey optimism
Stay active
Pain medication
Self care techniques
Follow-up
Pamphlet/information
Convey optimism
Exercise
Pain medication
Psychological evaluation
and possible cognitive
behavoral treatment
Work conditioning program
Ergonomic and/or
occupational intervention
Exercise
Aggressive pain management
Cognitive behavoral treatment
Multidisciplinary conditioning
program with focus on return
to work
Workplace intervention
Surgery (?)
100
50
0
W
o
r
k

d
i
s
a
b
i
l
i
t
y

i
n

%
1 month 3 months >6 months
Acute Subacute Early chronic Chronic
Figure 4d.1 Suggested management of occupational nonspecific low back pain.
the condition; feeling better; resuming activities, including work;
and avoiding recurrences.
Because compliance with regimens requires the patients active
participation, management of subacute NSLBP is demanding.
Compliance rates for different regimens have been reported to
vary from 13% to 85%,
2,61
and a patients decision to adhere to
a treatment regimen is complex.
50
Patients may prefer passive
treatment that may delay the course of recovery.
83
One study has
shown, for example, that patient compliance with video watch-
ing for back education (70-80%) in a physical therapy practice
was significantly higher than compliance with a more demanding
exercise regimen (40-50%).
2
Linton and Andersson
61
indicated
an adherence rate of 53% and 72% for six and four CBT sessions,
respectively.
Adherence appears to be influenced by both the type of treat-
ment and its frequency. The stepwise active approach includes an
exercise regimen or a CBT program as a single intervention or a
combination of the two as a bimodal treatment if no recovery
occurs.
Exercise regimens
The message here is for the patient to start moving with or
without help from a coach. There are many different types of
exercise regimens for LBP, each with its own proponents.
Exercise programs evaluated in randomized controlled trials
include the McKenzie regimen, walking programs, Williams flex-
ion exercises, endurance-strength-stabilization training, and
other less frequently described regimens.
23,27,43,47,54
Different types
of exercises appear to be equally effective.
1,87
A recent meta-analysis of five exercise studies involving
about 800 patients resulted in pooled weighted difference
decrease in pain of about two points (1.89 [95% CI, -1.13 to
4.91) on a scale of 100. Pooling four trials demonstrated an
improvement of 1.07 (95% CI, -3.18 to 5.32) points on a scale of
100 for perceived functional outcomes.
45
The authors concluded
that the evidence is insufficient to refute or support the effective-
ness of regimens involving exercise alone without a behavioral
component.
Cognitive behavioral therapy
CBT interventions include creative visualization, imagery, pro-
gressive muscle relaxation, problem solving, and other techniques.
The clinician uses the components in various combinations to
have the patient understand, accept, and take control of the back
pain. Moderate to strong evidence indicates that CBT should be
used early if biopsychosocial signs or symptoms are present, and
strong evidence exists for using CBT in patients with chronic
NSLBP.
33,87,96
The European Guidelines 2005 stated, We recom-
mend cognitive-behavioural treatment for patients with chronic
LBP, and summarized as follows:
There is strong evidence that behavioural treatment is more
effective for pain, functional status, and behavioural outcomes
than placebo/no treatment/waiting list control. There is strong
evidence that a graded activity programme using a behavioural
approach is more effective than traditional care for returning
patients to work, and finally there is strong evidence that there
is no difference in effectiveness between the various types of
behavioural therapy.
33
Combination therapy in occupational
settings
Three studies in occupational settings have found that a behav-
iorally oriented graded-activity exercise program provides mod-
erate to excellent reduction of days lost at work. This type of
program has been compared to usual care in the Netherlands
and in Sweden.
60,81,86
These studies had highly structured inter-
ventions with an unambiguous primary goal of returning the
patient to work.
A behaviorally oriented graded-activity exercise program
includes the following components:
1. The occupational or treating physicians advise workers on
ergonomics, prevention, and return to work schedules;
2. The clinicians also advise and communicate with interested par-
ties such as health care providers and workplace representatives;
3. The programs use gradually progressive exercises adapted to
patient needs;
4. The clinical team is trained, and all caregivers provide the
same message to the patient to avoid ambiguity;
5. There is ample communication and discussion with the patient;
6. An ergonomic intervention such as a workplace visit or a dis-
cussion with the occupational physician may be included.
60,62
The studies showed significant reduction in days of work
loss. Lindstrom et al,
60
for example, showed an average return to
work in the intervention group at 10 weeks (standard deviation,
12.7) and in the control group at 15.1 weeks (standard deviation,
15.6). Staal et al
80
showed an effect on work loss days (HR 1,9;
CI, 1.2-3.2) at 50 days after randomization in favor of the
graded-activity program. However, the results were not signifi-
cant in early follow-up less than 50 days after treatment for
the two interventions (an exercise program and a graded operant
conditioning program).
One randomized controlled trial in an occupational setting in
the Netherlands added problem-solving therapy conducted by
a trained therapist to a behaviorally oriented graded-activity
exercise program for patients with subacute and chronic NSLBP.
The combination group showed significantly favorable results,
including fewer work loss days and fewer patients receiving
disability pensions 1 year after the intervention.
86
In all studies, self-reported pain and function were affected
marginally.
60,80,86
Usually measured by a pain score or visual ana-
log scale, pain itself appeared not to be a major determinant for
return to work. Possibly the highly structured positive environment
in an occupational setting provides a better venue for problem
solving, educating the patient, and monitoring progress.
Ergonomic intervention
Using the Sherbrooke model of occupational/ergonomic interven-
tion and clinical rehabilitation, Loisel et al
62
found that a consulta-
tion with an occupational physician or a low-cost ergonomic
intervention contributed the most to the success of return to work.
In a follow-up study of cost effectiveness 6.4 years later, the same
authors found that the Sherbrooke model yielded the highest sav-
ings in work loss days compared with standard care or rehabilitation
alone.
64
The authors assessed participatory ergonomics in workers
suffering from subacute LBP (>6 weeks of work disability).
Performed 6 months after the ergonomic intervention, the assess-
ment included all parties: management, union, and afflicted worker.
About half of the recommended ergonomic solutions were imple-
mented with a substantial agreement among all respondents.
63
The Cochrane review of multidisciplinary biopsychosocial
rehabilitation concluded, There is moderate evidence showing
that multidisciplinary rehabilitation for subacute LBP is effective
and that a work site visit increases the effectiveness.
53
These
findings must be interpreted with caution, however, because the
few studies reviewed contained methodologic flaws and need to
be confirmed. Based on several studies of patients with chronic
back pain, the European Guidelines 2005 recommend an occu-
pational intervention.
33
MULTIMODAL PROGRAMS FOR CHRONIC LBP
Two recent reviews and one systematic Cochrane review of
chronic NSLBP showed the importance of multimodal active
programs.
9,10,19,39,42
The Cochrane review covered 18 trials,
including 1964 chronic NSLBP patients (Fig 4d.2).
53,87
The com-
parison included treatment such as back training, exercise only,
education, standard care, assessment by specialist with or with-
out a nurse and/or advisement (oral and printed), waiting lists,
and other factors.
Like the European Guidelines 2005, the review concluded,
There is strong evidence that intensive multidisciplinary biopsy-
chosocial rehabilitation for chronic NSLBP with a functional
restoration approach reduces pain when compared with in-
patient or out-patient nonmultidisciplinary treatments and mod-
erate evidence when these programs are compared to usual care.
There is contradictory evidence regarding global vocational out-
comes.
42
The authors cautioned about the lack of definition
concerning content, duration, and intensity of the programs but
found that those longer than 100 hours of therapy with a focus
on functional restoration seem to be more effective than less
intensive programs or nonmultidisciplinary control groups.
The review indicated significant and favorable results for pain
ratings, functional status, employment status, and sick leave up
to 60 months.
MANIPULATION
Manipulation has been evaluated extensively for chronic LBP
and studied less in the subacute phase. A recent pragmatic ran-
domized trial, however, included 181 general practices in the
United Kingdom with 1334 patients, most of whom had suba-
cute NSLBP. Patients were randomized to groups of standard
best care or manipulation, each with or without exercise, and fol-
lowed for 1 year.
85
Results on the Roland Morris disability ques-
tionnaire
76-78
improved with a mean of 3.3 (standard deviation, 4.5)
and 3.5 (standard deviation, 4.7) points out of a total score of
10 points at 3 and 12 months, respectively. A score change of
20% is deemed clinically significant.
10
The difference between
the groups was nonsignificant.
Manipulation for chronic NSLBP was reviewed extensively by
Assendelft et al,
4
Bronfort and Bouter,
13
and Cherkin et al.
25
In a
meta-analysis, Cherkin et al compared sham manipulation, trac-
tion, corset, bed rest, home care, topical gel, diathermy, massage,
general practitioner care, analgesics, physical therapy, exercises,
back training, no treatment, or some combination thereof.
They found no evidence that spinal manipulation is substantially
more or less effective than other conventional therapies for chronic
NSLBP. The expected gain in pain reduction is 4-5 points (ranging
from -4 to 12) on a 100-mm visual analog scale for pain of long-
term duration and somewhat less for self-reported disability. These
measures were reported for both the short and the long term.
25
A UCLA study (n = 681) included about 50% patients with
chronic NSLBP in a managed care health organization. The
patients were randomized to chiropractic, medical, or physiother-
apy care, and at a 6-month follow-up the results were comparable.
51
Chiropractic care in combination with physical modalities or phys-
ical therapy modalities provided in combination with medical care
did not produce clinically significant improvements in outcome.
58
The European Guidelines 2005
33
recommend a short course
of spinal manipulation/mobilization as a treatment option for
chronic LBP. They also summarize the evidence for medication
use as follows.
MEDICATION
Nonsteroidal antiinflammatory drugs
(NSAIDs)
The usefulness of nonsteroidal antiinflammatory drugs (NSAIDs)
was reviewed systematically by van Tulder et al,
89
who highlighted
the methodologic problems they encountered. Most of the pub-
lished trials reported on acute LBP. In comparison with placebo,
the authors found conflicting evidence that NSAIDs provided
better pain relief, but patients on NSAIDs exhibited significantly
less use of analgesics. There were no significant differences in
terms of side effects. In the same review, conflicting results were
found among studies comparing NSAIDs with paracetamol.
Included in the same systematic review were six studies comparing
NSAIDs with narcotic analgesics or muscle relaxants. The authors
found moderate evidence that NSAIDs are not more effective
than other drugs. van Tulder et al
89
highlighted the impossibility
of making any statement about the relative effectiveness of differ-
ent NSAID types because no studies comparing the same two
drugs for acute or chronic LBP were available.
Muscle relaxants
Benzodiazepine and nonbenzodiazepine muscle relaxants, either
isolated or combined with other drugs, have been extensively
investigated in LBP. A systematic review of this literature was
published by van Tulder et al.
90
Limited evidence from one study
favored diazepam (an intramuscular injection followed by 5 days
of oral treatment) versus placebo. The authors found strong
evidence both that oral nonbenzodiazepines are more effective
than placebo for short-term pain relief and that both types of
muscle relaxants are associated significantly more than placebo
with central nervous system side effects. Because the number of
high-quality studies comparing different muscle relaxants is
Chapter 4d Medication 129
2 1 0 1 0.1 10
Standardized
mean difference
2 2 1 0 1 1
Standardized
mean difference
Relative
risk
2 2 1 0 1
Standardized
mean difference
2
Intensive (>100h)
daily MBPSR with
functional restorative:
Alsants 1994*
v >100h inpatient
rehabilitation
Bendix 1995:1*
v<30h outpatient
rehabilitation
3 months
12 months
4 months
12 months
24 months
60 months
Bendix 1990
v usual care
4 months
24 months
60 months
Michel 1994*
v usual care
4 months
12 months
24 months
Less intensive (<30h)
once or twice daily
outpatient MBPSR:
Bazier 1997
v outpatient
rehabilitation
Bendix 1995:2*
v<10h outpatient
rehabilitation
At treatment
completion
Juckel 1990
S type MBPSR
v waiting list
At treatment
completion
6 months
12 months
24 months
30 months
Nichols 1991*
v<30h outpatient
rehabilitation
6 months
12 months
Nichols 1992*
v<30h outpatient
rehabilitation
6 months
Martapea 1989:2
v usual care
3 months
12 months
30 months
54 months
Other types
of MBPSR:
Martapea 1989:1
Inpatient MBPSR
>108h (no func-
tional restoration)
v usual care
3 months
12 months
30 months
54 months
Uritias 1989*
Individualized
inpatient MBPSR
v usual care
12 months
Trial
characteristics
Time since
treatment
Pain
record
Functional
status
Employment
status
Days on
sickness leave
Figure 4d.2 Treatment effect sizes for 12 randomized comparisons of multidisciplinary biopsychosocial rehabilitation and a control condition. Bars
represent standardized mean differences and 95% confidence intervals for comparison of intervention and control groups, except for employment
status, where bars represent relative risks. Treatment effect sizes entirely to the left of the vertical line indicate statistically significant differences
in favor of the intervention. *, High quality trial; I1, intervention 1 testing more than one multidisciplinary intervention; I2, intervention 2 testing
more than one multidisciplinary intervention; MBSPR, multidisciplinary biopsychosocial rehabilitation.
rather limited, it seems very difficult to make general recommen-
dations in this area. There is strong evidence that combining
tizanidine plus paracetamol or tizanidine plus NSAIDs is more
effective for short-term pain relief than placebo plus paracetamol
or plus NSAIDs.
Two high-quality trials offer strong evidence that temazepam
50 mg 3 times a day is more effective than placebo for short-term
pain relief and overall improvement. When the literature review
was published, however, this drug was available only in some
European countries and Mexico. Among the nonbenzodiazepines,
there is moderate evidence that flupirtine and tolperisone are more
effective than placebo for short-term improvement.
90
Opioids
Breckenridge and Clark
12
and Fillingim et al
35
independently
showed that the use of opioids in chronic LBP patients was not
predicted by pain intensity. Therefore, the factors influencing
health care providers to prescribe opioids probably deserve more
research.
Antidepressants
The efficacy of antidepressants in chronic LBP was systematically
reviewed by Staiger et al.
82
Based on the seven studies reviewed,
the authors concluded that tricyclic and tetracyclic antidepres-
sants can produce moderate symptom reductions. Inhibition of
norepinephrine reuptake seems important for the analgesic effect.
Benefits appear to be independent of a patients depression.
Selective serotonin reuptake inhibitors were evaluated in three
studies that failed to show any analgesic effect. It remains unclear
whether these drugs affect functional status.
Corticosteroids
In their review, Atlas and Nardin
5
stated that evidence support-
ing the use of oral corticosteroids is lacking. Because these drugs
have potential significant side effects, the authors therefore advised
against their use in patients with chronic pain.
SURGERY
Chronic NSLBP would imply LBP without sciatica in patients
with degenerative disk diseases.
30
Although shown to be contro-
versial, the diagnosis itself is usually made by provocative diskog-
raphy at the level of the disk possibly causing the pain.
19,20
An
et al
3
discussed disk degenerative progressive changes as part of
normal aging. Studies today cannot confirm what starts and what
influences progression if no trauma or disease is present. There is
also debate about the disk as a pain source; from a clinical per-
spective, however, severe disk degeneration on several levels is
shown to cause pain. Moderate to less visible disk degeneration
changes are more debatable. The authors argued for investigating
other sources of pain as well as its enhancers or modifiers.
A systematic literature review in 1999 concluded that there
was insufficient evidence for lumbar spine fusion in lumbar
spondylolysis and back pain.
39
Three randomized trials have since
shown that long-term benefits for surgery over 2 years is compara-
ble with those of nonsurgical treatments.
15,35,37
In a large random-
ized controlled study, Fritzell et al
36,37
compared fusion with usual
conservative care in patients (n = 294) with one- or two-level disk
degeneration and pain duration of at least 1 year. The surgical
group had a greater improvement in pain relief, function, depres-
sive symptoms, and return to work at 1-year follow-up compared
with those who had common conservative treatment prescribed by
a physician. At 2-years follow-up, the difference between the
groups had diminished, suggesting that the results of fusion are
intermediary rather than long term. The heterogeneous therapy in
the nonsurgical treatment may also have contributed to a less
favorable result in the nonsurgical group. The nonsurgical group
received a variety of treatments according to individual physician
preferences such as acupuncture, physical therapy, injections,
electrical stimulation, and CBT. The study did not have blinded
evaluators.
In a smaller randomized trial, 64 patients aged 25-60 years
with NSLBP lasting longer than 1 year and evidence of disk
degeneration at L4-L5 and/or L5-S1 at radiographic examination
were randomized to either lumbar fusion with posterior
transpedicular screws and postoperative physiotherapy or cogni-
tive intervention and exercises.
15
The cognitive intervention con-
sisted of a lecture to help patients understand that ordinary
physical activity would not harm the disk and a recommenda-
tion to use the back and bend it. This was reinforced by three
daily physical exercise sessions for 3 weeks. The main outcome
measure was the Oswestry Disability Index.
At a 1-year follow-up visit to 97% of the patients, the
Oswestry Disability Index was significantly reduced from
41/100 to 26/100 points after surgery, compared with 42/100 to
30/100 points after cognitive intervention and exercises. The mean
difference between the groups of 2.3 points (-6.7 to 11.4; p = 0.33)
was not significant. Improvements in back pain, use of analgesics,
emotional distress, life satisfaction, and return to work were not
different. Fear-avoidance beliefs and fingertip-floor distance were
reduced more after nonoperative treatment, and lower limb pain
was reduced more after surgery. According to an independent
observer, the success rate was 70% after surgery and 76% after
cognitive intervention and exercises. The early complication rate
in the surgical group was 18%.
The authors concluded that the main outcome measure showed
equal improvement in patients with chronic LBP and disk degener-
ation randomized to lumbar fusion or cognitive intervention and
exercises.
15
The risk for the nonsurgical group was considerably
lower, however, because no complications occurred. Although
the evidence is less compelling than it might have been, in the
future these patients may be offered surgery or CBT with similar
results. This study needs to be confirmed by other and larger
studies, but it may provide an alternative to surgery when
expected outcomes from that treatment are uncertain.
In a multicenter study from Great Britain,
34
349 patients with
chronic back pain lasting more than 1 year were randomized to
surgery (spinal fusion) or to an intensive rehabilitation program
for 5 days a week for 3 weeks continuously and followed for
2 years. The team included a physician, a physical therapist, and
a psychologist. The program was individually tailored to each
patient with progressive exercises and CBT to overcome fears
and negative beliefs about back pain. Both groups reported
Chapter 4d Surgery 131
reductions in disability, and the only primary outcome measure
that marginally favored surgery was the Oswestry Disability
Index, which showed a clinically insignificant decrease of about
four points on a scale of 100 (-.1 [95% CI, -4.1 to -0.1; p = 0.045).
No clear evidence emerged that primary spinal fusion was any
more beneficial than intensive rehabilitation.
Randomized controlled trials on novel technology such as artifi-
cial disks, electrothermal therapy, analgesic pumps, and implanted
stimulators are lacking. One systematic literature review stated,
There is no evidence that disk replacement reliably, reproducibly,
and over longer periods of time fulfills the three primary aims of
clinical efficacy, continued motion, and few adjacent segment
degenerative problems. Total disk replacement seems to be associ-
ated with a high rate of re-operations, and the potential problems
that may occur with longer follow-up have not been addressed.
28
Arthroplasty and fusion or laminectomy have been compared
in randomized clinical trials with similar outcomes.
41,68
In these
studies no nonsurgical groups were included for comparison, as
is greatly needed. In patients with chronic NSLBP, the current
evidence points to improved triage and a stepwise active
approach in which the patient and clinician discuss goals,
outcomes, and compliance with the proposed treatment.
COMPLICATIONS AND TREATMENT CHOICE
We could not find any complications reported in therapies includ-
ing exercise, CBT, or workplace intervention. The complication
rate for spinal surgery varies by type from 2% to 15%, including
instrument failure, prosthetic migration, infection, chronic pain,
and neural injuries or/and pulmonary embolus. When advising
a patient, this information can be used for education to help
with choice of treatment.
SUMMARY
This chapter summarizes evidence-based management and treat-
ment regimens for patients seeking care for LBP and diagnosed
with NSLBP. In acute NSLBP there is strong to moderate evidence
for self-care by taking over-the-counter medication and main-
taining activity as tolerated or engaging in limited sessions of
manipulative therapy.
In subacute NSLBP, there is weak to moderate evidence for a
graded activity program, including a combination of exercise and
CBT. Strong evidence indicates that these programs reduce work
absenteeism.
In NSLBP of more than 12 weeks duration, a variety of regi-
mens seems to be available with limited and similar efficacy on
pain and disability reduction. There is weak to moderate evidence
that interventions, including CBT, exercise, and education about
chronic NSLBP, are as effective as surgery after 2 years of follow-
up. Surgical indications for chronic NSLBP are ill-defined.
ACKNOWLEDGMENT
We thank Chaitrali Gore, M.S., for her excellent help with references and
figures.
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chances emerge for unplanned events. These then result in various
kinds of accidents with property damage and/or personal injuries.
A meaningful attempt to control such injuries makes it imperative
to understand them.
Most cases compensated by the Workers Compensation
Board are regional musculoskeletal problems. Workers in differ-
ent economic sectors generally have injuries characteristic of
those sectors. People in forestry, construction, and manufactur-
ing have a higher proportion of back injuries. Those working in
office jobs involving keyboarding have cumulative trauma disor-
ders (also called musculoskeletal disorders and repetitive strain
injuries). Because heavy physical workers do not develop repeti-
tive strain or injury of the upper extremity and office workers do
not injure their backs, the argument can be made that the nature
of the physical stress and the region enduring the load largely
determine the affected area and probably the nature of injury.
If therefore one could delineate the mechanisms of injuries
and the quantitative details of the relevant variables, one might
develop a more effective intervention. An effective intervention
would result in better control of injuries, which clearly has a sig-
nificant payoff. Thus, the long-term success in controlling these
injuries depends on understanding their causality.
Because for ethical reasons human beings cannot be sub-
jected to controlled experiments exposing them to risk of injury,
Kumar et al
16
performed an integrative synthesis of information
in the scientific literature to formulate biologically plausible the-
ories as to the mechanisms of injury causality. Through this exer-
cise they proposed four theories of musculoskeletal injury causality
described briefly below.
1. The Cumulative Load Theory
16
: Because biologic tissues are
composed of both solid and liquid, their combined mechan-
ical behavior or viscoelasticity is determined largely by the
proportion of these components. Biologic tissues therefore
deform partially like solids and partially like liquids in a
blended manner. Such properties are time dependent: a longer
exposure to the same load will produce larger deformation
and vice versa. As a result, recovery from deformation takes
time also. If the succeeding load does not allow sufficient
recovery time, the tissue begins to deform further from its com-
promised stage. As demonstrated by Kumar
13
in an epidemio-
logic study, repeated loading results in a cumulative effect of
reduced threshold to failure.
2. The Differential Fatigue Theory
16
: Occupational tasks are kine-
siologically complex and hardly ever performed in one plane.
Asymmetric activities requiring the use of many body parts of
the bilaterally symmetric human organism result in differential
unequal loads on various muscles, joints, and connective tis-
sue. One task may stress one tissue element to 80% of its capac-
ity, whereas another one is stressed only 10%. Additionally, this
distribution is not determined by the tolerance of the tissue con-
cerned. Such diverse distribution of stress results in one muscle
becoming more fatigued than others.
15,16
This differential
fatigue causes loss of coordination resulting in sudden and
significant stress concentration that precipitates an injury.
3. The Overexertion Theory
16
: The basic tenet of this theory is
that even a rested and normal tissue can, and probably will,
fail when the stress/load exceeds its tolerance time. Although
stressed and fatigued tissues cannot withstand stress concen-
tration, it is not necessary for tissues to reach that stage to fail.
for the Low Back Region
Shrawan Kumar and Steve Konz
THE NATURE OF LOW BACK PAIN
The nature of low back pain (LBP) and even its broad categoriza-
tion into acute, subacute, and chronic categories defy scientific
precision. In many cases, its insidious onset, relief without med-
ical intervention, recurrence despite all precautions, and eventual
chronicity have not only perplexed medical practitioners but also
posed an intellectual challenge even for a scientific conception
of the phenomenon.
Although many risk factors have been associated with LBP, its
etiology remains obscure. Kumar
14
categorized all known risk
factors into four broad categories: (1) morphologic, (2) genetic,
(3) biomechanical, and (4) psychosocial. He stated that whereas
morphologic and genetic factors are hardly manipulable, the
biomechanical and psychosocial factors lend themselves to
manipulation. It was, however, conceded that all strategies must
take into account the genetic and morphologic data for optimal
results. Many studies have been conducted to examine the pos-
sible impact of different risk factors, but the human back is
like a multilink chain that is only as strong as its weakest link.
Unfortunately, the weakest link is most elusive, being different in
different people and also at different times in the same individual
because of varying internal and external circumstances.
CAUSAL MECHANISMS AND CONTROL
Humans have evolved over millions of years into what they are
today. Evolutionary pressures and consequent speciation resulted
in an upright biped creature with dextrous upper limbs and a
highly evolved brain. For a large duration of its existence, the
species relied on hunting and gathering as its primary means of
sustenance.
5
With the advancement of science, technology, and
industrialization, the physical occupational stresses have changed
dramatically in an evolutionary flash so that none of the body
systems that one uses today was either designed or evolved for the
current purpose. As a result, demand for force exertion, activity
repetition, or posture assumption for prolonged periods places
stress on human physical systems that is inherently unnatural.
This is further aggravated by many psychologic stresses emanating
from financial or interpersonal factors.
In addition, most human occupations have become complex,
requiring significant organization and thereby enhancing the
chances of errors. As a function of a multivariate complex system
(in many cases under multiple partial controllers), significant
C HA P T E R
4e
4. The Multivariate Interaction Theory
16
: Over and above
the three previous theories, the variability in the individual
threshold indicates also that a precipitation of musculoskeletal
injury may be modulated by the interaction of genetic, mor-
phologic, psychosocial, and biomechanical factors. Within
each of these categories are many variables that may potentiate
an injury. Interaction between the relative weights of the vari-
ables and the extent to which these have been stressed in any
given individual determines the final outcome.
Although these four theories have been presented as distinct,
all four are simultaneously operative but to a different degree
depending on the circumstances and individuals. As pointed out
above, humans have not evolved over the past 250 million years
to be industrial workers. Humans will therefore always find
themselves in the middle of a conflict between their nature and
an industrial requirement. Such a backdrop clearly makes occu-
pational injury prevention not only a daunting and lofty goal
but an unachievable objective. Control of injuries to reduce their
incidence and severity, however, remains a goal that may be
achieved to varying degrees. With this in mind, Kumar
12
presented
a strategy to quantify the risk based on the discrete physical
elements of the task in question.
THE EXTENT OF THE PROBLEM
As a medical condition LBP has only one redeeming featureit
is not fatal. In spite of the obscurities associated with its etiology,
classification, and treatment, human and economic impacts have
been approximately quantifiable. Chapter 4a on the epidemiology
of LBP offers a comprehensive picture of the problem; suffice it
to say here that it is a large social and economic one. Although
it occurs in less developed countries also, the impact of LBP is
much more recognized in Western and industrialized countries.
To put the extent of the problem in perspective, a brief
description follows. Andersson
1
stated that national statistics
from the European countries reveal 10% to 15% of all sickness
absence to be due to back pain, with the number of work days
lost per worker increasing steadily. An annual prevalence of 25%
to 45% was reported, and chronic back pain was present in 3%
to 7% of the adult population. The lifetime prevalence of LBP
has been variously reported as between 70% and 80%. In Canada,
LBP has steadily constituted approximately 27% of all industrial
injuries; these have been reported to cost disproportionately higher
amounts than all other injuries.
In the United States, the annual prevalence has been reported
to be in the 15% to 20% range. Khalil
8
reported that on any given
day, roughly 75 million Americans have back pain, 6.5 million of
whom are in bed. Webster and Snook
23
reported the cost of LBP in
1989 incurred by Liberty Mutual, the largest insurer in the United
States; it constituted 16% of the claims and accounted for 33% of
the total expense. They reported also that the mean cost per case of
LBP was $8300 compared with $4100 for all other claims com-
bined, whereas the median cost was $396 ($168 for other claims).
In these claim settlements, 34% of the total cost for LBP was med-
ical, whereas 66% was indemnity cost for lost time and wages.
23
No matter which way one looks, LBP is prevalent and expensive.
Some of the socioeconomic aspects of our society may accentuate
the problem because of the alleged secondary gain. We have been
able to reduce neither the incidence nor the severity of LBP; a
cure neither exists nor is likely to emerge in the foreseeable future.
No difference in long-term outcome between aggressive and con-
servative treatments has been identified, and we seem unable to
control the problem in a significant or meaningful way. LBP is
clearly here to stay.
It is therefore of utmost importance to focus on workplace
adaptations to reduce human suffering and economic cost. Our
endeavor to identify these adaptations must try to reduce the mag-
nitude of identified risk factors and the exposure of workers to
them, decrease the incidence of LBP in healthy people, and reduce
stress in patients who already have the condition. Such adapta-
tions will be helpful in returning workers to work after injury.
DISABILITY CAUSED BY LBP
LBP is associated with considerable disability that results in work
loss, its most important social and economic consequence
despite the influence by many other factors. A direct correlative
scale between LBP, disability, and work loss has not been estab-
lished. A simple clinical and subjective assessment of disability,
however, has been claimed to have considerable relevance to
quality of life as well as industrial performance. This assessment
is focused on loss of function rather than pain. The emphasis is
on whether an activity can be performed by an individual or is
restricted because of LBP. Implicit in this assumption is that the
restriction must have its onset coincident with that of the back
pain and must therefore be the functional limitation. The specific
criteria used by Waddell et al
21
are as follows:
1. Bending and lifting
2. Sitting
3. Standing
4. Walking
5. Traveling
6. Social life
7. Sleep
8. Sex life
9. Dressing/undressing
The aforementioned criteria combine postural, strength, meta-
bolic, and everyday living activities that are involved also in occu-
pational activities. LBP and loss of function through disability are
results of biomechanical (kinematic and kinetic) perturbation of
the human system. These demands are covered in Chapter 4b,
but we note here that the functional activities accentuating these
demands are divided into two main categories: static load (sitting,
holding) and dynamic load (pushing/pulling, carrying, and lifting/
lowering). The concentration must therefore be on those activities
that reduce hazards for initial injury and subsequent recurrences.
ADAPTATIONS
Static work
Spitzer et al
20
report the LBP incidence in Quebec, Canada of
individuals required to do heavy work but also include sedentary
Chapter 4e Workplace adaptation for the low back region 136
work areas such as government, wholesale and retail, and finance
and insurance. Magora
17
reported on LBP for bank tellers and
for those who perform heavy work.
Seated work
Problem
Because intervertebral disks are avascular, their nutrition depends
entirely on diffusion. Intervertebral disks also are viscoelastic.
While an individual is sitting, the load on the intervertebral disk
is 140% of that imposed by standing. This static load progres-
sively decreases the water content of a disk; an increased load
accelerates this process. Loss of water from a disk makes the
diffusion process more difficult and results in reduced oxygen
tension and lack of nourishment, leading to disk degeneration.
Sedentary occupations involve prolonged exposure to static
loads, hastening this process and making the disk more vulnerable
to injuries. A constant static load also deforms the viscoelastic disk
and causes compression creep. Because creep is time dependent,
elimination of a load does not immediately restore either the pre-
load disk configuration or the water content. The reduction in
water and oxygen is therefore prolonged, interfering with disk
metabolism by decreasing the amount of glycosaminoglycans
(which have a strong affinity for water) and increasing the content
of keratan sulfate (which is amorphous with far less capacity to
imbibe water). In the short term, the viscoelastic deformation may
lead also to laxity of the ligament and lack of coordination, poten-
tiating injury through biomechanical perturbations. Over the long
term, it leads to degenerative and permanent changes that are a
hazard to the back.
The problem of seated sedentary work worsens considerably
when prolonged sitting is combined with whole-body vibration,
such as with truck driving. The frequencies of many vehicles are
close to the natural frequency (4 to 8 Hz) of the human spine,
causing resonance and thus amplification of the motion ampli-
tude. Truck drivers must contend not only with this vibration
but also with the static loading of the disk while driving. In addi-
tion, often they have periodic acute loading of the back when
they load or unload their vehicles.
Control strategies
The two strategies for addressing this problem are personal com-
pensations and job design. From a personal viewpoint, people in
sedentary jobs should lead active lives outside the workplace. In
addition, at work they should be encouraged to change postures
frequently, move around, and mix nonseated with seated work.
(Naturally, the job design should not just permit this movement
but also encourage it.)
Job designs of seated workers often include either machines or
other workers to bring supplies and remove finished products.
By not allowing the worker to move, this practice creates a
straight jacket that precludes movement. Permitting a worker
to fetch supplies and dispose of products not only is beneficial
but also should be encouraged within limits. Another possibility
for permitting some movement is to have a sit/stand work
station where the worker can alternate between sitting and stand-
ing. Standing work is better if there is a bar rail or footrest
upon which the worker can alternate foot positions.
9
Avoid using
stools; both conventional and sit/stand chairs should have back-
rests. Sit/stand chairs should have a forward tilt of 15-30 degrees
and a fabric seat.
4
Another technique to encourage movement is job rotation.
A chair is the key component of seated work, but because not all
seated work is the same, chairs should be matched to specific
jobs. Of course, people vary in height and weight, and many of
them often sit in the same chair because of multiple shifts, part-
time workers sharing a shift, and holiday or vacation replacements.
Thus chairs should be easily adjustable in terms of seat pan
height, back rest height and forward/back location, and armrest
width and height. The seat should be padded with a breathable
fabric; avoid plastic and leather. It should not be contoured,
because this reduces micropostural changes. A curved front edge
(waterfall front) maximizes contact with the underside of the
thigh; avoid upholstered beading on the front edge. Normally,
the seat should tilt backward 1-5 degrees and permit swiveling.
For seat width, the wider the better; for depth, the most common
problem is a seat that is too deep. A deep seat forces the sitter
forward (losing support of the backrest) or back (with the legs
dangling). The ideal backrest is adjustable both horizontally and
vertically and has a spring action so that it tracks the angle of
the back as the person moves. It should be concave to give area
support to the back, especially in the lumbar region. Armrests
should be adjustable in width and height. Avoid long armrests that
hit the table edge and preclude good chair location with respect to
the task. The legs/pedestal normally should permit swiveling and
thus micropostural changes. The sitters legs should be able to tuck
under the seat to shorten the hamstrings (reducing their pull) and
decrease stress on the back. If the seated worker moves about the
work station, the chair should have casters; otherwise, they are
inadvisable because they force the operator to use leg muscles to
keep the chair still. Design modifications to truck seats should
reduce vibration at the point of origin or dampen it before trans-
mission to the driver. Trucks should be equipped with hoists and
dollies to reduce acute stress on the back by doing the work.
Holding work
Problem
For some tasks in auto assembly, painting, or kitchen and laundry
work, for example, workers hold an object without movement.
Even without an object, the weight of one hand and arm is
approximately 4.9% of body weight. The farther from the spine
the hand or object, the greater the problem, because torque is a
product of weight times moment arm.
Control strategies
To address this problem, reduce the torque and its duration.
Figure 4e.1 shows how a tipping aid can reduce the strain of
holding a drum or container. An angled bar (a plow) on a belt
conveyor can direct a product on the conveyor toward the side
closest to the worker, who need not reach as far for the item and
therefore reduces torque on the spine. For standing workers, a
conveyor should be about 50 mm below the elbow (by height
adjustment or by having short operators stand on platforms) to
minimize torque on the arms and back. A balancer (Fig. 4e.2)
reduces tool weight.
Chapter 4e Adaptations 137
Figure 4e.1 Tipping aids permit a drum or carboy to be counterbalanced
when pouring. The danger of spills and operator muscle stress is
reduced.
Figure 4e.2 Balancers reduce tool weight from pounds to ounces.
Note that the balancer is suspended from a job crane to minimize
horizontal force as the tool is moved about the workplace. The greater
tool weight increased torque at the elbow and shoulder, thereby
decreasing comfort of the neck and back as well as the arm (Ulin S,
Armstrong TJ, Snook SH, Monroe-Keyserling W: Examination of the
effect of tool mass and work postures on perceived exertion for a
screw driving task. Int J Ind Ergonom 12:105-115, 1993).
Dynamic work
Manual handling is quite prevalent in industry. Asfahl
2
estimated
that for every pound of product, 80-150 pounds of materials are
handled and moved. Konz and Johnson
9
stated that 25% of all
industrial injuries are associated with manual handling670,000
injuries per year in the United States. Of money spent on industrial
injuries, 60% pays for those caused by manual handling, which
accounts for 93,000,000 work days lost each year. Dynamic work
risks are divided among pushing/pulling, carrying, and lifting/
lowering, the last of which causes most problems.
Pushing and pulling
Imrhan
7
provided an excellent summary of pushing/pulling.
Pushing occurs not only while standing but also while sitting
and even kneeling. Height and direction also are important
(Fig. 4e.3).
Control strategies
A poor interface of the hand and handle is a potential weak link.
Although a handle is needed for pulling, pushing may just use a
flat surface. Two hands are better than one. The arm and shoulders
(rather than the back) tend to be limiting (causing local muscle
fatigue) when the activity is repetitive. Workers should avoid push-
ing or pulling above the shoulders or below the hip. Effective
pushing involves leaning toward the load with the rear foot posi-
tioned behind the bodys center of mass (Fig. 4e.4), whereas
pulling involves leaning away from the load with the rear foot
behind the bodys center of mass.
Although there should be a high coefficient of friction
between the floor and the shoe, the object may have a low coef-
ficient of friction against its supporting surface. Ball transfer sec-
tions on conveyors have a kinetic friction of 0.03 to 0.15, for
example, so pushing a 50-kg container on balls requires a force
of 1.5 to 7.5 kg. Air-film pallets use the same concept of reduc-
ing the friction of object against surface. Generally, people
push/pull perpendicular to the shoulders. When pushing parallel
to the shoulders, the capability is 50-60% of the perpendicular
capability. Several recommendations for force limits for pushing
and pulling have been published.
18,19
In summary,
Two hands are usually better than one.
Force capability decreases when it is used more often.
Initial force capability is higher than sustained capability.
Pushing capability is higher than pulling capability.
Pushing should be done at waist level and pulling at thigh

level.
Carrying
Although carrying objects for long distances (those over 10 m)
no longer is common in developed countries, workers still carry
around work stations. Carrying objects up and down stairs is
especially dangerous because the hands are holding the object
and thus not free to grasp handrails if there is a slip and because
the object may obstruct vision.
Control strategies
Long-distance carrying is best when mechanized with lift trucks,
conveyors, or carts (Fig. 4e.5). As anyone who has transported a
suitcase through an airport knows, pushing or pulling is better
than carrying, so wheels should be used whenever possible.
Jib cranes, ball-transfer sections, or manipulators (Fig. 4e.6) can
move objects within work stations, as do ramps and elevators
between floors.
Lifting and lowering
As pointed out above, manual handling creates many problems.
Engineers and ergonomists can focus on the job-specific factors
with reference to the detailed tables of the manual handling
guide.
18
For example, Table 4.2 of the guide gives 720 recom-
mended weights for male industrial workers for two-handed sym-
metric lifting for 8 hours. The table has three box sizes, eight lifting
frequencies, six lifting distances, and five population percentiles.
The most common approach is that set forth in the National
Institute for Occupational Safety and Health (NIOSH) lifting
guideline.
22
The NIOSH guideline assumes a load of 23 kg but
then reduces the 23 through 6 multipliers (all less than 1.0) to
arrive at a recommended weight limit (RWL):
RWL = LC HM VM DM FM AM CM
where LC is the load constant (i.e., 23 kg), HM is the horizontal
multiplier, VM is the vertical multiplier, DM is the distance mul-
tiplier, FM is the frequency multiplier, AM is the asymmetry
multiplier, and CM is the coupling multiplier. Konz and
Johnson
9
explain the calculation procedure in detail, and the
disk accompanying the book has a computer program to solve
the equation.
Control strategies
1. Select strong people based on tests: Several studies have
shown the significance of the job severity index, the ratio of
the task demand to the persons capability. One approach
may therefore be to select workers with large capacities. It is
important to consider worker capacity in job-simulated tests,
which force the analyst to measure not only this factor but
also the task requirements.
2. Bend the knees: Despite a concerted effort to train workers to
lift with bent knees and straight backs, the practice has not
received universal acceptance. The logic behind the recom-
mendation has been to reduce the moment arm on the lum-
bosacral disk, thereby reducing mechanical compression.
It has been shown, however, that unless the object to be lifted
is brought very close to the body, the squat lift can in fact
significantly increase mechanical compression on the lum-
bosacral disk. It has been shown also that the squat lift is asso-
ciated with significantly higher physiological cost and is more
tiring for workers.
Figure 4e.3 Chiming a drum (rotating a tipped drum) requires little effort; with skill, the drums momentum can be used to move it onto a pallet.
A drum cart is another alternative. A straight push, however, as shown on the right, requires considerable effort.
Typical posture
Recommended posture
Figure 4e.4 Posture when pushing makes a difference. Peak intraabdominal pressure was 50% less when pushing with the back (Ridd J:
A practical methodology for the investigation of materials handling problems. In T Kvalseth, ed: Ergonomics of work station design. London,
1983, Butterworth-Heinemann).
Another disadvantage of the squat lift is that it causes con-
siderable stress on the knees, which are also a frequent site of
mechanical disorders. Therefore a universal acceptance of the
squat (as opposed to the stoop) lift is neither physiologically
nor mechanically sound. It is perhaps for this reason that this
method has not been accepted by workers as widely as was
initially hoped. Furthermore, the statistics of low back injuries
associated with lifting over the past 40 years make clear that a
steady increase in incidence has occurred despite many indus-
trial workers following the squat method. It is important to
assess the job as well as the individual performing it before
recommending squat or stoop lifting.
Garg et al
6
compared the physiologic costs of different meth-
ods of lifting. They found that when subjects were allowed to
lift any way they wanted, they chose neither pure stoop nor
pure squat but combined the features of both in a freestyle
lift. This lift was found to be metabolically the least expen-
sive. The recommendation is therefore to use an individual-
and task-specific method to minimize stress on spine and
reduce the chances of injuries.
3. Dont slip or jerk: Sudden and ballistic movements have a
large inertial component. Because of the viscoelastic nature of
the human back and the resistance to immediate deformation
offered by the fluid portion of the tissue, such inertial forces
can exceed the tolerance limits of the tissues.
16
In addition,
sudden motion may also cause a slip or fall while performing
a lift. It is therefore recommended that workers wear shoes
with soles having a large contact area and a high coefficient
of friction, as should floors, which must not be smooth. Data
on a force platform indicate that peak forces and torques dur-
ing lift are very spiked, with the peak force often occurring
during initial lowering of the body before the object is even
grasped. The accelerations and decelerations during lifting
and lowering should be fast enough that the body gets the
benefit of the momentum without causing a jerk that may
lead to an injury.
4. Avoid twisting: To maintain symmetry of the human body,
the spine is provided with a bilaterally symmetric arrange-
ment of muscles and ligaments. Any rotation accentuates
the activities in the agonist group of muscles and reduces the
A
B
C
Figure 4e.5 Drum carts reduce stress. (A) A two-wheeled cart; it should have a latch over the top rim during movement. (B) The foot can be
used to help tip the drum. Another handle forward of the main handles is useful when tilting and maneuvering the drum to scales and pallets.
(C) A four-wheeled cart useful for heavier drums; note that the hand positions are different.
contribution of the antagonistic muscles. When manual
materials are handled, a twisted posture or when the spine is
progressively twisted during a lift, the force production in dif-
ferent muscles is continually varied, accentuating the stress
on one group of muscles and ligaments. When most of
the load is borne by only 50% of the structures, the stress
could easily be doubled, significantly increasing the chances
Figure 4e.6 Manipulators (balancers with arms) can support tools or
can be used to move products around work stations.
of injury. Twisting while bent over, such as when removing
parts from the floor, is risky. A general recommendation is
therefore for workers to move their feet instead of twisting
their backs. Because workers might not comply as rigorously
as desirable, an engineering approach precluding the need to
twist is recommended. Such an approach will solve the prob-
lem rather than depend on the workers knowledge, aware-
ness, alertness, and cooperation. Figure 4e.7 shows how a task
can be modified to reduce bending and twisting.
5. Use mechanical aids: The most desirable means of preventing
injuries associated with manual materials handling is to elim-
inate it by using mechanical aids. Instead of moving a power
tool around a work station, for example, a balancer (Fig. 4e.2)
or manipulator (Fig. 4e.6) can be used. Figure 4e.8 shows a
turntable on a scissors lift used to mechanize palletizing; in
automation, the operator would be replaced with a palletizer.
In some circumstances robots are appropriate. Other machines
commonly used to eliminate manual handling are hoists, lift
trucks, conveyors (both portable and telescopic), and lever arms.
6. Consider the packaging: For job design, an important con-
cept is to keep the load close to the body, so it is important
to keep packages small. Big, bulky, and awkward packaging
increases the moment arm of the load on the spine, thereby
increasing the compressive load significantly. Bulk may make
it more difficult to lift 25 kg of feathers, for example, than 25 kg
of iron. Konz and Coetzee
11
reported that increasing a boxs
volume up to a 30-cm cube did not bother men but strongly
bothered women. When determining packaging dimensions,
it is therefore important to consider the anthropometry of the
work population.
7. Have good coupling: Cardboard boxes with cutout holes pro-
vide poor coupling because (1) the hand cannot rotate as the
object is lifted from the knee to the waist and (2) the narrow
cardboard surface area tends to concentrate the load on a
small area of contact with the hands, thereby cutting the
circulation and squeezing the muscles. When the packages to be
lifted are larger than optimal size, it is particularly important
to provide a comfortable handhold to permit a relatively risk-
free, orderly, and smooth lifting activity that minimizes the
chance of injury.
8. Consider work height and reach: Konz stated, Drag it, pull
it, push it, but dont lift it.
10
As explained above, if lifting is
necessary, it is best done at knuckle height; loads should not be
on the floor or above the shoulders. When cartons are loaded
from a conveyor, for example, the conveyor height should be
adjustable. When they are loaded from a pallet, it should be left
on the lift truck forks, the height of which should be periodi-
cally adjusted. If the fork lift cannot be tied up, the pallet
should be placed on a wheeled lift table.
A summary of all these principles has been provided by
Ayoub et al
3
in a comprehensive set of guidelines to control and
reduce occupational health problems associated with manual
materials handling. Their recommendations can be summed up
in two statements: (1) eliminate heavy manual materials han-
dling and (2) decrease the stress to the worker. They recommend
the use of mechanical aids such as hoists, lift tables, and convey-
ors and the provision of best work heights that can be varied to
suit the operator and achieve an optimum work arrangement.
Figure 4e.8 Turntables can reduce stress when loading or unloading. The
turntable is rotated after a few items are moved. It can be mounted on the
floor and a pallet placed upon it. If the turntable surface is rollers, ball
casters, or an air table, rotation can be manual. If it is mounted on a scissors
table (as shown), horizontal transfer can replace lifting and lowering.
Figure 4e.7 Work station positioners reduce lifting, bending, and twisting. (A) A scissors lift. (B) A bin on an adjustable-height cart that is useful
to create temporary work stations for tasks such as shelf stocking. (C) A self-leveling truck (similar to cafeteria tray dispensers).
A reduction of stress, they suggest, can be achieved by reducing
the weight of the object in cases in which it is not possible
to split the load between two workers. A reduction in the size
and weight of containers is a desirable goal also. The authors
recommend changing the type of manual materials handling:
lower the load rather than lift, push the load rather than pull, and
pull the load rather than carry. They suggest reducing both the
horizontal and vertical distance in reaching for an object and
transporting it. Avoiding twisting in both standing and seated
work is desirable. Modification of an object to make it easier to
handle by using handles, balance containers, and reasonable
width are all good design criteria. On the worker side, however,
it is important also to provide adequate recovery time by reduc-
ing the frequency with which a particular task is performed and
allowing for job rotation.
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1. Andersson GBJ: The epidemiology of spinal disorders. In J Frymoyer, Spitzer W,
LeBlanc FE, Dupuis, M eds: The adult spine. New York, 1991, Raven Press,
pp. 107-146.
2. Asfahl CR: Industrial safety and health management. Englewood Cliffs, NJ, 1984,
Prentice Hall.
3. Ayoub MM, Selan J, Jiang B: Manual material handling. In G Salvendy, ed: Handbook
of human factors. New York, 1987, Wiley & Sons.
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ergonomics handbook. Boca Raton, 1999, CRC Press.
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2004, Holcomb Hathaway.
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Horizons.
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39(12):504-510, 1970.
18. Mital A, Nicholson A, Ayoub MM: A guide to manual material handling. London,
1993, Taylor & Francis Publishers.
19. Snook SH, Ciriello VM: The design of manual handling tasks: revised tables
of maximum acceptable weights and forces. Ergonomics 34(9):1197-1213,
1991.
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Advance Lifts (work station positioners) www.advancelifts.com
American Lifts (scissors lifts) www.americanlifts.com
Autoquip (lifting, turning, tilting equipment) www.autoquip.com
Bishamon Industries (pallet positioners, lift tables) www.bishamon.
com
Columbus McKinnon (lift tables) www.cmworks.com
Columbus McKinnon (manipulators) www.positech-solutions.com
Econolift (lifts/tilters) www.econolift.com
Ergonomic Systems (work station/positioners) www.
ergonomisystems.com
Glasgow (air tables) www.glasgowproducts.com
Knight Industries (balancers, manipulators) www.knight-ind.com
Presto Lifts (work station material handling) www.prestolifts.com
Rampmaster (work station material handling) www.rampsonline.
com
Scaglia America (balancers, manipulators) www.scaglia.it
Southworth (work positioning) www.southworthproducts.com
Tawi USA (vacuum lifting) www.tawi.se
Vestil (work positioning) www.vestilmfg.com
Appendix 4e.1
Websites of workstation suppliers
C HA P T E R
Shoulder and Elbow
5
of the elbow. Cubital tunnel external compression syndrome
is caused by compression of the ulnar nerve at certain elbow
flexion angles at a subcutaneous location behind the humeral
epicondyle (cubital tunnel).
EPIDEMIOLOGY
General population
In general studies that include large sample populations without
special demands for neck and shoulder activity, the 12-month
prevalence of neck and shoulder disorders was 15% to 18%.
5,94
Disorders of the neck and shoulders are most common among
women.
7,21,93,94
In a Swedish study, 50% of the women but
only 36% of the men reported strain injuries from the neck and
shoulders.
44
Another study reported a 10 times higher rate of sick
leave due to occupational cervicobrachial disorders in women
compared with the sick leave in men due to occupational low
back pain.
51
Perhaps even more than men, women often work in
occupations with repetitive and monotonous work tasks, and
many studies have reported an increased prevalence of upper
limb disorders in repetitive work.
32,47,58,78,92
In a large Swedish
study of 2537 men and women, 20% of the women and 16% of
the men had neck-shoulder problems during the last 12 months,
92
the incidence of which increased with age and occupational
physical load. Takala et al reported a 1-year prevalence of 18%
of women and 16% of men in a Finnish rural population.
89
In
a random sample of 855 men and women in Iceland, 65% of
the women and 43% of the men had neck or shoulder pain
during the previous year.
79
Neck and shoulder pain has been
found to be not only interrelated but also related to low back
pain, indicating a susceptibility and a predisposition to develop
MSDs.
63
Occupational risk groups
Epidemiologic studies show, and most researchers agree, that
along with personal factors such as age, genetics, and gender,
exposure to a combination of physical and psychosocial work-
place risk factors is a major contributor to these disorders.
Specific physical factors include intense, repeated, or sustained
exertions; awkward, sustained, or extreme body postures; insuffi-
cient recovery time; vibration; and cold temperatures. Specific
examples of workplace psychosocial factors include monotonous
work, time pressure, high workload, lack of peer support, and a
poor supervisor-employee relationship.
34
Musculoskeletal diseases were the major reason for long-term
absenteeism in a manufacturing company. Low back pain
accounted for 17.7% of all long-term absenteeism (the greatest
amount), and neck and shoulder pain caused 15.9%. Back disor-
ders were most common in heavy manufacturing workshops,
whereas in the light manufacturing workshops the most domi-
nant diseases related to the neck and shoulder.
51
As recorded in a questionnaire and compared with a control
group with more varied tasks, females employed in assembly,
fish-processing, and ceramics factories, all representing highly
repetitive work tasks, had considerably higher prevalences of
Shoulder and Elbow
Disorders
Marianne Magnusson and Malcolm Pope
This chapter discusses the epidemiology and pathomechanisms
of disorders of the shoulder and elbow. Shoulder and elbow dis-
orders were reported as related to certain occupations as long ago
as 1713.
80
Like other musculoskeletal disorders (MSDs), those of
the upper extremity are increasing, as expressed by a more fre-
quent reporting of them as occupational diseases.
65
The reason
for the increase might be the higher degree of automation result-
ing from workplace designs improved to reduce heavy workloads
like lifting and manual labor. The demands of increasing produc-
tivity, however, which in turn imply the simplification of work-
ing tasks, has increased the work pace.
96
CLASSIFICATION OF DISORDERS
Shoulder
In the International Classification of Diseases,
99
work-related
neck-shoulder disorders have been classified into occupational
diseases, in which there is a direct cause-effect relationship
between hazard and disease, and work-related disease, in which
work environment and the performance of work contribute
significantly, but as one of a number of factors, to the causation
of a multifactorial disease.
98
The concept of occupational cervicobrachial disorder was
adopted in 1973.
6,61
It is defined as functional and/or organic
disturbances resulting from neuromuscular fatigue to doing
jobs in a fixed position or with repetitive movement of the
upper extremities. Waris
93
named four categories: the cervical
syndrome, the tension neck syndrome, humeral tendinitis, and
thoracic outlet syndrome.
Introduced in Australia, the term repetition strain injury is
defined as a soft tissue disorder caused by muscle overloading
from repetitive use or maintenance of constrained postures that
occurs among workers performing tasks involving frequent
repetitive movements of the limbs or the maintenance of fixed
postures for prolonged periods.
12
Cumulative trauma disorder,
musculoskeletal injury and disorder, occupational repetitive
strain injury, and regional pain syndrome are other terms that
describe essentially the same condition.
Elbow
Tennis elbow, also called lateral humeral epicondylalgia or lateral
elbow syndrome, is a painful condition of the lateral aspect
C HA P T E R
5a
complaints and physical examination diagnoses of neck and
upper limb disorders.
70
Without a specific diagnosis or defined symptoms, neck
and shoulder problems have been reported in a large number of
studies involving secretaries and office workers,
10,41,42,56,91
den-
tists,
55,68
sewing machine operators,
86
visual artists and piano
players,
16,27
and railway station workers.
13
The annual prevalences
of neck and/or shoulder symptoms for female secretaries and
office workers ranged from 45% to 63%, whereas those for male
office workers were considerably lower, ranging from 16% to
27%. Table 5a.1 reports the elbow problems found in a study
surveying workers in the newspaper industry.
82
Musculoskeletal problems in instrumental musicians have a
long history.
25,26
Lederman and Calabrese
52
described an increas-
ing number of reports of musculotendinous overuse. Nerve
entrapment syndromes have been reported in musicians by
Knishkowsky and Lederman.
48
Charness et al
17
reported that
routine electromyography (EMG) and nerve conduction studies
were abnormal in less than half the musician patients studied,
attesting to the potential for even mild ulnar neuropathy to
produce disabling symptoms.
RISK FACTORS
Work-related factors
Work-related factors recognized for their association with upper
limb disorders include repetitive or forceful exertions, awkward
postures, and segmental vibration. Several studies have suggested
a relationship between static and/or repetitive load and disorders
in the neck and upper extremity.
30,44,51,60,95
In their meta-analysis
of occupational neck-shoulder disorders, Hagberg and Wegman
32
found that jobs with highly repetitive shoulder muscle contrac-
tions, static muscle work, and work above shoulder level were
associated with the tension neck syndrome. Kuorinka and
Forcier
49
looked specifically at shoulder tendinitis and stated that
the epidemiologic literature is most convincing regarding work
relatedness, showing an increased risk especially from overhead
and repetitive work.
Several studies have supported these associations
4,16,27,72,86
; the
mechanical load on the shoulders was obvious, and working
tasks involving continuous arm movements always generate a
static load component.
1,72,85,97
Repetitive work should therefore
not be considered independent of posture. Association between
repetition and shoulder tendinitis has been reported in three
studies,
23,71,73
in all of which some or all of the results showed
Chapter 5a Shoulder and elbow disorders 150
Table 5a.1 Elbow problems in newspaper workers
(% of total)
82
All Office Production
12-month
prevalence (%) 8 6 12
Missed work (%) 1 1 2
n 906 682 201
associations with a combined exposure to repetition and
awkward posture.
The principal muscle to carry this load is the trapezius. The
relative load as a percentage of maximum voluntary contraction
(MVC) on the upper trapezius has been shown to increase lin-
early with the relative torque in the glenohumeral joint.
29
There
are large differences, however, among muscles and between flex-
ion and abduction. A given shoulder torque during flexion pro-
duces smaller amplitudes of both the intramuscular pressure and
the EMG than for the same torque during abduction.
38
With a
shoulder abduction of 30 degrees, the intramuscular pressure in
the supraspinatus muscle by far exceeds the level at which the
blood flow is significantly impeded. The supraspinatus is thus
extremely vulnerable in work situations requiring arm elevation.
High shoulder muscle force requirements can cause increased
muscle contraction, which may lead to an increase in both mus-
cle fatigue and tendon tension and may possibly impair micro-
circulation as well. Sjgaard et al
86
found that muscular fatigue
would occur at EMG levels as low as 5% of MVC if sustained for
1 hour. Other studies have demonstrated that when the period
of muscle contraction is extended to more than an hour, the
endurance limit of force may be as low as 8% MVC.
40
Workers
performing repetitive work with the hands and wrists while
maintaining static upper arm elevation may experience fatigue
even at low load levels. Jonsson et al
40
reported that many con-
strained work situations are characterized by static load levels
near or exceeding 5% MVC even when there is a fairly low mean
muscular load.
Ohlsson et al
71
reported an odds ratio of 3.03 (95% confidence
interval, 2.5-7.2) for supraspinatus, infraspinatus, or bicipital ten-
dinitis for work in the fish industry, representing repetitive work
and poor posture. Compared with that of a referent population,
the odds ratio for assembly work, which requires repetitive arm
movements with static shoulder load, was 4.2 (95% confidence
interval, 1.35-13.2).
Kurppa et al,
50
Silverstein et al,
85
and others reported that
highly repetitive tasks can cause pain and disability in the upper
extremity. In many jobs, upper extremity tasks require repetitive
contractions of those muscles over long periods of time at low
contraction intensities and short contraction-relaxation cycles.
Silverstein et al
85
created a prevention index to rank industries by
averaging the ranks of their number of claims and their claims
incidence rate with a focus on nontraumatic soft tissue MSDs.
Although the incidence rates for some disorders are decreasing,
the overall rate is not decreasing as fast as that for all other claims.
In some cases, the rate is stable (sciatica, rotator cuff syndrome)
or increasing (epicondylitis).
The industries with the highest risk are characterized by heavy
manual handling and repetitive work. Edwards
22
proposed that
fatigue and lack of recovery are the elements that can cause
injury to the elbow. In simulations of upper extremity work
measuring recovery of blood flow, EMG fatigue index, and
subjective ratings, Bystrm and Kilbom
15
concluded that a mean
contraction intensity of higher than 17-21% MVC was not
acceptable. Using the same techniques, Bystrm and Franson-
Hall
14
suggested in a later article that continuous handgrip con-
tractions higher than 10% MVC are to be avoided. These
recommendations are conservative, and many industrial jobs
exceed the safety limits.
Overall, epidemiologic evidence suggests a relationship
between repeated or sustained shoulder postures with more than
60 degrees of flexion or abduction and shoulder MSDs, including
both tendinitis and nonspecific pain. The evidence for increased
risk of MSDs due to specific postures is strongest with a combi-
nation of exposures to several physical factors such as force
and repetitive work. An example would be holding a tool while
working overhead.
Insufficient evidence exists to make an association between
shoulder tendinitis and exposure to segmental vibration.
Stenlund et al
88
found such an association, but work with vibra-
tion exposure also placed a large static load on shoulder muscles
so that the effects of forceful exertions could not be separated
from it.
Because they are multifactorial in origin, shoulder MSDs are
and may be associated with both occupational and nonoccupa-
tional factors whose relative contributions may be specific to
particular disorders. The confounders for nonspecific shoulder
pain, for example, may differ from those for shoulder tendinitis.
(Two of the most important confounders or effect modifiers for
shoulder tendinitis are sport activities and age.)
Excessive contractions or fatigue can lead to tennis elbow, one
of the most common occupational elbow problems.
19
This is char-
acterized by intense pain of the lateral aspect of the elbow exacer-
bated by grip and more use. Coonrad
18
reported that the main
problem is repetition, but it is multifactorial in origin. Allander
3
reported a prevalence of one third in 15,000 subjects. In studies at
certain occupational clinics, Dimberg
20
found that 64% of all diag-
nosed cases were related to work. Cyriax
19
reported that only 8%
of cases actually involved tennis. In a review, however, Maylack
67
reported that 50% of competitive tennis players suffer from at least
one episode of lateral epicondylitis.
Another elbow problem is cubital tunnel external compres-
sion syndrome. As the ulnar nerve travels from the brachial
plexus to the hand, it is vulnerable to compression at certain
elbow flexion angles at a subcutaneous location behind the
humeral epicondyle (cubital tunnel). A common occupational
risk reported in drivers occurs where the elbow is rested on a
hard surface for a long period of time.
2
Mansukhani and
DSouza
66
reported unilateral ulnar neuropathy in diamond
workers that was restricted to the arm holding the eyeglass for
inspecting the diamonds.
Individual factors
Not all workers performing similar and risky work tasks develop
MSDs, due to the obvious influence of individual factors on the
exposure-effect relationship. The individual factors most fre-
quently studied or controlled for are sex and age. Some studies
have shown that age affects the prevalence of MSDs,
36,47,54,91,94
whereas others have shown no such influence.
11
Muscle strength and endurance influence the risk of neck and
upper limb disorders. With higher muscle strength, the muscle is
obviously less loaded than in the case of lower strength for the
same force exertion. Women in general have lower strength than
men, in particular in the upper extremities, and older people are
weaker than younger ones.
69
Some studies, however, have shown
that compared with men, women have longer muscle endurance
in proportion to their muscle strength,
10,84
but this has not been
proven for all muscle groups. Although women may have more
neck-shoulder disorders than men because of fatigue and poor
strength, it is more likely because women predominate in jobs
involving a high degree of repetitiveness and prolonged static
postures of the neck and shoulders.
Poor muscle strength and low endurance have been shown in
patients with neck-shoulder pain. Strength was affected in acute
patients,
9,51
whereas endurance was impaired in chronic patients as
well.
31,86,87
Other studies, however, failed to show a relationship
between neck and shoulder symptoms and strength and
endurance.
46
Indeed, the contrary was shown in a prospective
study; subjects with high muscle strength in shoulder elevation
seemed to be at a higher risk.
40,45
A longitudinal study of motor
assembly workers showed that low isometric strength of shoulder
muscles was a risk factor for neck and shoulder pain.
43
Hgg et al
33
could not show significant relations between either EMG signs of
fatigue during work or isometric strength with the development of
muscular disorders during a 2-year follow-up.
A few studies found certain personality traits to predispose to
MSDs. Characterized by competitiveness, impatience, and a
feeling of time urgency, the type A personality has been found
to be associated with low back pain
36,37,94
and with neck-shoulder
pain.
24,33,83
Social factors
Along with recognition of the importance of the physical load to
MSDs, there is a growing awareness of their association with psy-
chosocial factors and work environment.
59,64
In a longitudinal
study, job satisfaction and relations with coworkers and supervi-
sors were the strongest predictors for developing industrial back
pain.
7,8
Monotony, stress, low job satisfaction, lack of control,
and low skill requirements characterized a typical light assembly
job where young males reported a high rate of back pain.
57,62
In
a study of occupational drivers, the group that had the highest
incidence of both back pain and neck-shoulder pain reported the
highest stress level and lowest job satisfaction.
63
The same study
found a strong relationship between back pain and neck-shoulder
pain also, indicating that individuals who are predisposed will
develop any or several MSDs. Tola et al
91
reported that moderate
or poor job satisfaction and physical loading factors were signif-
icant risk factors for neck and shoulder pain. Bergenudd et al
7
found that women with a history of shoulder pain were less
satisfied with their jobs than women who did not experience
pain. Among possible psychologic stresses at work, the combina-
tion of high work demand and low control in particular seems to
play an important role in the development of musculoskeletal
complaints.
36,37
PATHOMECHANISMS
Workload
The common causative factor in MSDs is mechanical stress on
musculoskeletal tissues. Normally, the tissues adapt to mechani-
cal stress; that is, tissues strengthen with increased stress and
Chapter 5a Pathomechanisms 151
weaken with less.
90
When the stress exceeds the limit of adap-
tion, pathologic changes may occur in the tissue. The risk of
developing symptoms may also increase, however, when the
physical stress is very low.
99
Hagberg and coworkers
31,32
suggested three possible pathomech-
anisms for muscle pain as a result of physical load: mechanical fail-
ure, local ischemia, and energy metabolism disturbances.
Mechanical failure of the muscles is typically the cause of the mus-
cle soreness that occurs 24 to 48 hours after heavy physical exer-
tion. The pain is due to ruptures of the z-disks and outflow of
metabolites from the muscle fibers, which directly or through
edema activate pain receptors. Local ischemia produces an accumu-
lation of metabolites within the muscle that is typically a result of
static or repeated muscular contraction or repeated muscular
injuries. Energy metabolism disturbances occur when the energy
demands exceed the production. Because of the prolonged replen-
ishment of intracellular glycogen stores, the resulting development
of muscle pain may be delayed up to 46 hours. Edwards
22
proposed
another model for pathologic changes in the muscle after occupa-
tional injury, suggesting that occupational muscle pain might result
from a conflict between motor control of the postural muscular
activity and that needed for movement or exertion.
Some studies have been conducted to provoke pain or discom-
fort in the shoulder-neck region. Hagberg
29
studied the immediate
and long-term effect of continuous repetitions of shoulder flexions
with and without weights for 1 hour or until exhaustion. He
found that all subjects had pain localized to the descending part
of the trapezius muscle directly after the experiments. In 14 of
18 experiments, the subjects had pain 24 hours later, and after
48 hours, tenderness occurred in the trapezius muscle and the
rotator cuff insertions. Harms-Ringdahl and Ekholm
35
studied
the effect of prolonged extreme flexion of the neck and found
that pain was experienced after 15 minutes and increased with time.
Interestingly enough, the pain disappeared within 15 minutes, but
in 9 of 10 subjects it recurred the same evening or the following
morning and lasted for up to 4 days. Lee and Waikar
53
found a cor-
relation between EMG root-mean-square values and discomfort
ratings in subjects simulating microscope work for 4 hours.
Muscular fatigue
Muscular fatigue is related to the force of the active muscle;
that is, fatigue develops faster with higher relative muscle force.
Some muscle groups are more prone to fatigue than the neck and
trunk extensor muscles.
28,77,81
Limits to muscular load for con-
strained work with a duration of 1 hour or more were proposed
by Jonsson
39
: static muscular load should not exceed 2-5% of
MVC, mean load level should be limited to 10-14% of MVC,
and peak loads should occur within 50-70% of MVC.
Entrapment
Radial tunnel syndrome, also known as resistant tennis elbow, is
seen in workers who must perform multiple repetitive motions,
especially wrist extensions with or without force. The mechanism
behind the condition is the entrapment of the radial nerve
involving its sensory branch.
PREVENTION
According to Hagberg and Wegman,
32
the occupationally related
etiologic fraction of neck and upper extremity injuries is high,
and therefore a relatively large number could be prevented.
Some studies have proved that intervention in working condi-
tions can be successful,
76
and rehabilitation of neck and upper
limb disorders often fails when not combined with such
improvements.
23,75
Only a few studies have been able to describe
an exposure-effect relationship. For successful prevention, future
studies of the quantification of physical exposure and the impor-
tance of psychosocial factors are needed.
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is implicated in a significant proportion of shoulder pathology,
limitation of motion at the AC joint leads to minimal alterations
in normal shoulder function.
53
Like the SC joint, the AC joint
possesses an intraarticular meniscus that enhances the contact
area between its two incongruent articular surfaces. The AC joint
is stabilized by two sets of ligaments: the AC ligaments are
primarily condensations of the AC joint capsule, whereas the
coracoclavicular ligaments include the more medial conoid and
laterally based trapezoid ligaments.
Scapulothoracic Articulation Not a true joint, the scapulotho-
racic articulation represents the sliding and rotation between
the bony thorax and the scapula. The scapula lies flat on the
chest wall and is enveloped by muscle. The complex interaction
between the scapular and thoracic muscles affords stability and
additional rotation for the scapula on the posterior thorax. This
in turn changes the orientation of the glenoid surface and signif-
icantly contributes to shoulder range of motion and function.
Because the scapulothoracic articulation is not a true joint, it has
no discrete ligamentous attachments.
Glenohumeral Joint Often likened to a sideways golf ball on a
tee, the glenohumeral articulation allows more range of motion
than that of any other major joint in the body. The joint itself
is composed of the head of the humerus laterally, which articu-
lates with the glenoid of the scapula medially. The glenoid is
shaped like a pear, being broader distally and narrow proximally.
It is covered in cartilage that is thin at the center and thickens
more peripherally. Along the outer edge of the glenoid is a rim
of thick fibrous soft tissue, the glenoid labrum, which deepens
the articular surface and also acts as the origin for the long head
of biceps (LHB) tendon and the glenohumeral ligaments.
The articular surface of the humerus extends medially from
the anatomic neck to form approximately one third of an irreg-
ularly shaped sphere. Unlike the more static midline structures
on the chest wall that lie in the standard anteroposterior plane,
the shoulder lies in the scapular plane. Viewed from above,
the scapula is anteverted 30 degrees to lie flat on the curved
posterior chest wall. This placement is balanced by a 30-degree
retroversion of the humeral head.
The joint capsule of the shoulder is a thin redundant sleeve
of fibrous tissue that extends from the glenoid neck to the
anatomic neck and variable areas of the proximal shaft of the
humerus. The primary ligamentous structures at the glenohumeral
joint are the coracohumeral and the three glenohumeral ligaments
(Fig. 5b.2). The coracohumeral ligament (CHL) arises from the
coracoid process and attaches to the greater and lesser tuberosi-
ties of the humerus. The glenohumeral ligaments are essentially
condensations of capsule extending from the rim of the anterior
articular surface of the glenoid to the head of the humerus. They
provide significant stability to the joint and appear as discrete
structures when viewed arthroscopically. The superior gleno-
humeral ligament extends from the tubercle of the glenoid ante-
rior to the LHB tendon origin and inserts at the proximal tip of
the lesser tuberosity. The middle glenohumeral ligament spans
the distance between the anterior superior labrum and supragle-
noid tubercle to the lesser tuberosity, where it blends with the
subscapularis tendon. The strongest and most important of the
glenohumeral ligaments, the inferior glenohumeral ligament
Biomechanics of the
Shoulder and Elbow
Complex
David I. Pedowitz, David P. Beason, and Louis J. Soslowsky
During physical activity, the forces acting on the shoulder and
elbow have been estimated to be upward of several times body
weight.
1
Many workplace activities are known to involve heavy
manual labor and chronic repetitive motion. Accordingly, the
resultant forces and associated pain perceived at the shoulder
and elbow can be greater at work due to the stress on the upper
extremity when larger loads are applied.
25,51
Also of importance
are work tasks involving postures nearing or exceeding the
normal range of joint motion, stationary postures over extended
periods of time, highly repetitive motions, and excessive loading.
A fundamental appreciation for the anatomy and biomechanics
of the shoulder and elbow complexes serves as an excellent
foundation for better understanding these injuries.
THE SHOULDER
Anatomic considerations
Because the shoulder is the primary conduit through which forces
travel from the hand and elbow to the axial skeleton, a thorough
understanding of the anatomy is paramount when considering its
function and relation to patients symptoms. The shoulder com-
plex is essentially composed of three bones, the clavicle, the
scapula, and the proximal humerus, which participate in four prin-
cipal articulations (Fig. 5b.1). Through these joints, the shoulder is
acted on by nearly 30 different muscles that either affect the shoul-
der itself or connect the upper extremity to the spine and the chest
wall. The following anatomic descriptions are meant to introduce
the critical concepts of shoulder form and function.
Articulations
Sternoclavicular Joint The most medial articulation in the
shoulder complex, the sternoclavicular (SC) joint is comprised
of the medial clavicle and the proximal part of the sternum,
the manubrium. This joint serves as a strut connecting the axial
skeleton to the upper extremity. The congruity of the articulation
is enhanced by an intraarticular disk, which also confers some
stability and cushioning for the two bony surfaces. The joint has
some limited motion in nearly all directions that is stabilized by
surrounding tough ligamentous structures.
Acromioclavicular Joint Similarly to the SC joint, the acromio-
clavicular (AC) joint is a conduit for forces from the distal upper
extremity to the central axis of the body. Although the acromion
C HA P T E R
5b
Chapter 5b Biomechanics of the shoulder and elbow complex 156
Supraspinatus fossa
Spine
Neck
Infraspinatus fossa
Scapula
Humerus
Clavicle (cut)
Coracoid process
Acromion
Greater tubercle
Head of humerus
Anatomical neck
Surgical neck
Infraglenoid tubercle
Deltoid tuberosity
Olecranon fossa
Lateral epicondyle
Trochlea
Groove for ulnar nerve
Medial epicondyle B
Coracoid process
Clavicle (cut)
Neck
Subscapular fossa
Infragneloid tubercule
Glenoid
cavity of
scapula
Head of
Humerus
Scapula
Humerus
Acromion
Supraglenoid
tubercle
Anatomical neck
Greater tubercle
Lesser tubercle
Surgical Neck
Intertubercylar
groove
Deltoid tuberosity
Medial
Lateral
Condyles
Radial
fossa
Lateral
epicondyle
Capitulum
Coronoid fossa
Trochlea
Medial epicondyle
{
A
Figure 5b.1 Bones of the shoulder region, anterior
(A) and posterior (B) views.
(IGHL), arises from most of the anterior glenoid labrum and
inserts on the inferior margin of the humeral articular surface,
around the anatomic neck of the humerus.
Another important structure at the glenohumeral articulation
is the coracoacromial arch, the osseoligamentous roof of the
shoulder region formed by the coracoid process, the coracoacro-
mial ligament, and the acromion of the scapula. Beneath the
coracoacromial arch is the subacromial space, the rotator cuff,
the LHB tendon, and the head of the humerus. In varying degrees
of shoulder pathology, the undersurface of the acromion or
leading edge of the coracoacromial ligament can impinge against
the rotator cuff and LHB tendons.
Muscles
The largest and most appreciable muscle in the shoulder region is
the deltoid, which defines the thick rounded contour of the healthy
shoulder. The muscle consists of three major sectionsanterior,
middle, and posteriorthat are variably active in different aspects
of shoulder motion. Overall, the deltoid is active in all forms of ele-
vation.
13
Table 5b.1 describes the muscles of the shoulder.
Chapter 5b The shoulder 157
Clavicle
Trapezoid
ligament
Conoid
ligament
Coraco-
clavicular
ligament
Coracoid process
Capsular
ligaments
Anterior view
Acromion
Coracoacromial ligament
Supraspinatus tendon (cut)
Coracohumeral ligament
Greater tubercle and
Lesser tubercle
of humerus
Transverse ligament of humerus
Subscapularis tendon
Biceps brachii tendon (long Head)
Figure 5b.2 Capsular and ligamentous structures of the shoulder, anterior view.
Table 5b.1 Muscles of the shoulder
Muscle Origin Insertion Innervation Action
Deltoid Lateral one third of clavicle, acromion, Deltoid tuberosity of humerus Axillary n. (C5-C6) Shoulder flexion, extension,
and spine of scapula abduction, some internal/
external rotation
Biceps Short head: coracoid process of Tuberosity of the radius and Musculocutaneous n. (C5-C6) Forearm flexion, supination of
scapula forearm via bicipital flexed forearm
Long head: supraglenoid tubercle of aponeurosis
scapula
Subscapularis Subscapular fossa of scapula Lesser tuberosity of humerus Upper and lower subscapular nn. Internally rotates and adducts
(C5-C7) humerus
Supraspinatus Supraspinous fossa of scapula Greater tuberosity of humerus Suprascapular n. (C4-C6) Abducts humerus
Infraspinatus Infraspinous fossa of scapula Greater tuberosity of humerus Suprascapular n. (C5-C6) Externally rotates humerus
Teres minor Superior border of lateral scapula Greater tuberosity of humerus Axillary n. (C5-C6) Externally rotates humerus
Teres major Inferior border of lateral scapula Medial lip of intertubercular Lower subscapular n. (C6-C7) Adducts and internally rotates
groove of humerus humerus
Trapezius Spinous processes of C7-T12 Lateral one third of clavicle, Spinal accessory n. (CN-XI) Elevates, retracts, and rotates
vertebrae acromion, and spine of scapula
scapula
Latissimus dorsi Spinous processes of T7-T12 vertebrae Floor of intertubercular groove Thoracodorsal n. (C6-C8) Extends, adducts, and internally
and iliac crest of humerus rotates humerus
Serratus anterior Lateral surface of ribs 1-8 Anteromedial border of the Long thoracic n. (C5-C7) Protracts and rotates scapula
scapula medially
n., nerve; nn., nerves.
The rotator cuff is a series of coalesced tendons from four
muscles. Moving over the head of the humerus from anterior
to posterior, these muscles include the subscapularis, supraspina-
tus, infraspinatus, and teres minor, which work in concert to
stabilize and afford discrete motion of the shoulder. These mus-
cles originate from the scapula and form a condensed tendinous
sleeve around the anterior, superior, and posterior aspects of
the humeral head. The most anterior muscle, the subscapularis,
fans out from the anterior scapula over to the lesser tuberosity
of the humerus. When contracted, it acts as an internal rotator
of the humerus.
At the most superior portion of the cuff is the supraspinatus,
the rotator cuff muscle most often implicated in shoulder
pathology. In its course to its insertion, it travels beneath the
coracoacromial arch, forming the floor of the subacromial space.
In this space between the acromion and the supraspinatus ten-
don is the soft subacromial bursa. The relationship between
the supraspinatus and the acromion is important to appreciate,
especially when considering conditions like impingement syn-
drome, where the subacromial space may be appreciably decreased
in size, leading to pathology. When contracted, this muscle is a
shoulder abductor in the plane of the scapula.
6
Moving posteri-
orly on the cuff, the infraspinatus muscle functions to depress
the humeral head and externally rotate the humerus. The final
and most posterior rotator cuff muscle, the teres minor, is an
external rotator of the humerus.
Although thought of primarily as an elbow muscle, the biceps
has a role in shoulder stability and pathology also. The biceps
is unique in that it is one of the bodys few muscles that origi-
nate within a joint. Because of this intraarticular labral origin,
the LHB is implicated in a great deal of labral pathology.
Although functioning primarily as an elbow flexor and supinator
of the forearm, the biceps is believed to play a role in the shoul-
der as a humeral head depressor and as a significant stabilizer
to inferior subluxation.
33,60
A number of other parascapular muscles act around the shoul-
der joint but do not necessarily contribute directly to gleno-
humeral range of motion or stability. The three largest of these
are the trapezius, serratus anterior, and latissimus dorsi muscles.
The bulky trapezius muscle mainly functions as a scapular
retractor. By doing so, it rotates the inferior angle of the scapula
laterally, shrugs the shoulders, and clamps the scapula to the
chest wall. Sometimes known as the boxers muscle, the serra-
tus anterior primarily protracts and medially rotates the scapula,
drawing it closer to the posterior chest wall. The serratus anterior
is active in all motions of the humerus but more so in flexion.
The latissimus dorsi is an enormous back muscle that internally
rotates and adducts the humerus and extends the shoulder.
Biomechanics of the glenohumeral joint
Kinematics
This concise discussion of biomechanics focuses on the primary
source of motion at the shoulder, the glenohumeral joint.
It should be noted however, that the AC, SC, and scapulotho-
racic articulations do also have roles, albeit less so, in the overall
mechanics of the upper extremity.
Glenohumeral kinematics describes the motion of the humeral
head in the glenoid cavity without consideration of forces
contributed by surrounding musculature. This description can
be for either two-dimensional planar motion or three-dimensional
spatial motion.
49
Planar motion of the glenohumeral joint can be
divided into three modes of articulation: sliding, spinning, and
rolling
41
(Fig. 5b.3). In sliding, the contact point is constant on
the translating humeral head but is always changing on the
stationary glenoid cavity. The center of rotation is the center of
curvature of the glenoid. During spinning, the contact point is
always changing on the rotating humeral head but is constant on
the stationary glenoid cavity. The center of rotation for spinning
is the center of curvature of the humeral head. In rolling, the
point of contact is always changing on both the humeral head
and the glenoid cavity, with the center of rotation being the
contact point itself. Any two of these three divisions can be com-
bined to describe the planar motion of the glenohumeral joint.
41
Spatial motion can best be explained in terms of degrees of
freedom. In general, an unconstrained rigid body has six degrees
of freedomthree translations and three rotations about the
orthogonal x-, y-, and z-axes (Fig. 5b.4). In its normal range of
motion, the glenohumeral joint is capable of three rotations
about three orthogonal coordinate axes and thus has three
degrees of freedom. In terms of joint motion, these three rota-
tions are defined as flexion/extension, abduction/adduction, and
internal/external rotation. These motions are constrained by soft
tissues, ligaments, articulations, and muscles. In flexion/exten-
sion, the humerus can generally be moved in the sagittal plane
through a range of about 170 degrees.
41
Abduction/adduction can
be achieved over a range of 180 degrees
41
in the coronal plane.
The range of motion for internal/external rotation totals approx-
imately 150 degrees.
41
Many overhead motions are achieved
through combinations of flexion/extension and abduction/
adduction, with additional aid from the scapulothoracic artic-
ulation at motion extremes. This type of overhead motion has
been reported as a source of numerous shoulder injuries, includ-
ing those suffered during occupational tasks.
22
Constraint
The bony architecture of the shoulder affords this joint an excep-
tional range of motion. It is achieved, however, only with an
obligatory reduction in its biomechanical stability. In compen-
sation, both static and dynamic stabilizers help orchestrate a
balance between mobility and stability.
When viewing plain radiographs, the glenohumeral joint
appears to function like a sphere articulating on a flat glenoid
surface. Historically, it was therefore assumed that the osseous
geometry of the joint surfaces provided little if any inherent
stability to the shoulder. Cadaveric studies, however, have deter-
mined that the articular geometry of the shoulder does play a
substantial role in stabilization. Using gross measurements and
magnetic resonance imaging, investigators have documented
that the radius of curvature of the average glenoid is about 2 mm
greater than that of the corresponding humeral head.
28
Using stereophotogrammetry, another center reported similar
findings and determined that the mating humeral head and
glenoid articular surfaces were in fact congruent.
58
When the
articular cartilage surfaces were analyzed, furthermore, it was
Figure 5b.3 Planar glenohumeral articulation. Included
are spinning, rolling, and sliding motions. These motions
may occur either in isolation or in combination. (From
Zuckerman JD, Matsen FA: Biomechanics of the shoulder.
In M Nordin, VH Frankel, eds: Biomechanics of the
musculoskeletal system. Philadelphia, 1989, Lea & Febiger.)
3
2
5
6
4
1
z
y
x
Figure 5b.4 Orthogonal coordinate axes, illustrating six degrees of
freedomthree translations (1-3) and three rotations (4-6).
observed that the actual articulating surfaces conformed more
than previously thought.
58
Enlarging the articulating area is
thought to add to stability by decreasing the potential for
humeral head translation and by increasing what Fukuda and
colleagues
17
referred to as the constraining wall height of the
joint. Using this technique
57
and Fugi Prescale film,
69
contact
areas within the glenohumeral joint have been documented also,
ranging from approximately 0.75 cm
2
with the arm at the side
and 5 cm
2
at 90 degrees of abduction. Additionally, contact
pressure within the joint was found to decrease with increasing
abduction to 90 degrees.
69
The remaining static stabilizers of the shoulder joint include
the glenoid labrum, the joint capsule, and the glenohumeral and
coracohumeral ligaments. These coordinate to resist joint
translation primarily by preventing displacement through their
presence and secondarily by imparting increased joint contact
forces resisting the displacement.
24
The first of these structures,
the glenoid labrum, is a meniscus-like thickening of fibrous
tissue that is triangular in cross-section and surrounds the rim
of the glenoid cavity (Fig. 5b.5). Previously thought to be com-
posed of fibrocartilage, the labrum is mostly dense fibrous tissue
with few elastic fibers.
43
Often conceptualized as a bumper that
prevents the humeral head from excursion out of the glenoid,
its role in enhancing the stability of the glenohumeral joint
has been questioned, as some investigators have found that it
offers little in overall shoulder stability.
43,63
As a whole, however,
the labrum does play some role in shoulder constraint, but its
contribution is likely complementary.
41
The joint capsule of the shoulder is a relatively thin sheet of
fibrous tissue. Depending on the position of the shoulder, the
capsule imparts a variable contribution to glenohumeral joint
stability. In general, anterior shoulder structures are taut when
the arm is externally rotated. Superior, inferior, and posterior
structures are accordingly tightened when the arm is adducted,
abducted, and internally rotated, respectively. The most obvious
and important portions of the shoulder capsule that confer
stability are sometimes referred to as the capsule-ligament com-
plex. This complex consists of superior, middle, and inferior por-
tions that along with the CHL define the ligamentous structures
providing constraint to the shoulder joint
41
(Fig. 5b.6). In gen-
eral, the capsular structures participate in mechanically stabi-
lizing the joint at the extremes of motion, though they may also
have roles in proprioception.
Because it extends from the coracoid process to the lesser
tuberosity, the CHL is thought to participate in suspending the
humerus in the glenoid when the arm is at the side. Its role in
stability, however, remains controversial.
60
The superior gleno-
humeral ligament is a fibrous structure that becomes tight when
the arm is adducted at the side. As it tightens, it acts primarily
as an inferior stabilizer and likely functions along with the
CHL and the rotator cuff to prevent inferior translation of
the humeral head on the glenoid.
48,68
Often well developed, the
Anterior View
Posterior View
Intraspinatus
Teres minor
Posterior axillary
pouch of IGHL
Supraspinatus
Long head
of triceps
SGHL
MGHL
Subscapularis
Superior band
of IGHL
Anterior axillary
pouch of IGHL
Capsule
Long head
of triceps
Figure 5b.6 The glenohumeral ligaments. The glenohumeral
ligaments are thickenings in the capsule of the shoulder and function
as passive check reins, particularly at the extremes of motion.
middle glenohumeral ligament has been demonstrated to be a sig-
nificant constraint to anterior displacement of the humerus.
14,43
Along with the anterior capsule, the middle glenohumeral ligament
becomes taut when the arm is abducted and externally rotated.
The IGHL is the ligament thought to be responsible for
most of the shoulders static stability. Its geometry has classically
been described as having three distinct componentsa superior
Shoulder Anatomy and Biomechanics
A B
Figure 5b.5 The glenoid labrum. The labrums role can be
thought of as extending the surface area of the socket, much as
adding to the bank of a road deepens a curve. (From Flatow E:
Shoulder anatomy and biomechanics. In M Post, L Bigliani,
E Flatow, R Pollock, eds: The shoulder: operative technique.
Philadelphia, 1998, Lippincott, Williams & Wilkins.)
band and anterior and posterior axillary pouches.
65
The geome-
try and mechanical properties of these distinct areas of the IGHL
suit it well for its role as the primary static anterior stabilizer
of the glenohumeral joint.
8
Slack and redundant with the arm
adducted, the IGHL is the primary static restraint to anteroinfe-
rior subluxation, particularly in abduction and external rotation,
a position associated with increased anterior instability.
9
In this
position the more anterior structures become taut, whereas in
internal rotation the posterior aspect of the IGHL is tense.
The dynamic stabilizers of the shoulder joint include the
rotator cuff, biceps, and deltoid muscles. Directly they act as a
bulky barrier with inherent passive muscle tension that resists
translation of the humeral head, and they play an important role
in stability by providing compressive forces on the humerus
into the glenoid socket. Indirectly, the dynamic stabilizers exert
their effect by moving the joint into positions that tighten the
capsular-ligamentous complex,
41
thus engaging these stabilizing
structures.
As described in the section on anatomy, the rotator cuff is
a series of four muscles that coalesce to form a tendinous arc of
tissue around the glenohumeral joint. In addition to affording
the shoulder with discrete motions, these muscles also provide
stability. Anteriorly, the subscapularis muscle forms a musculo-
tendinous curtain from the scapula to the lesser tuberosity.
In doing so, it is thought to be the most important dynamic
anterior stabilizer.
15
This stability is greatest in external rotation
and from 0 to 45 degrees of abduction.
36,65
At 90 degrees of
abduction, the IGHL seems to play the most important role.
65
Of all the rotator cuff muscles, the subscapularis provides the
most resistance to posterior subluxation when the arm is in for-
ward flexion.
10
Superiorly, the supraspinatus muscle has been
reported to be an important restraint to inferior translation of
the humerus. This action has been observed in cadaveric speci-
mens where the supraspinatus was found to be an inferior stabi-
lizer more effective than any other cuff muscle.
60
Investigators
demonstrated that moving posteriorly on the cuff, the infra-
spinatus, the teres minor, and occasionally the supraspinatus
function together with the subscapularis to impart notable
posterior stabilization.
10,46
A complete analysis of the relative contributions of the rotator
cuff muscles to glenohumeral joint stability is beyond the scope
of this text. It is notable, however, that these muscles do not
simply exist and function in isolation. Rather, they have been
demonstrated to function in concert, with both anterior and
posterior force coupling that yields enhanced joint stability.
54
The contribution of the biceps muscle to overall glenohumeral
stability is also important. As the LHB tendon courses over the
curved head of the humerus, it acts like a cable wrapping around
a pulley. When the biceps is activated, it compresses the humeral
head into the glenoid.
4
Additionally, the biceps has been sug-
gested to be as important as the rotator cuff to glenohumeral
stability.
29
Because of its size (20% of overall shoulder muscle
mass), the deltoids contribution to shoulder stability is thought
to be noteworthy but remains undefined.
7
Kinetics
In contrast to kinematics, glenohumeral kinetics is the study of
joint motion with respect to the forces responsible for it. The
muscles and ligaments of the rotator cuff carry appreciable loads
in day-to-day activities and in strenuous work tasks such as heavy
lifting, abduction, and overhead use. The loading that occurs in
the glenohumeral joint during normal motion has been reported
to be as high as 0.89 times body weight at 90 degrees of abduc-
tion, and it is increased appreciably when weight is held.
50
Most of the strength and gross motion at the joint is facili-
tated by the massive deltoid muscle, the three primary sections
of which function differently depending on the direction of
a force and the arm position when a load is applied. In general,
the more anterior portion is important in forward elevation,
whereas the posterior portion plays a significant role in posteri-
orly directed motion such as extension. The middle fibers of the
deltoid make relative contributions to both of these movements
but are involved mostly in shoulder abduction strength, to
which the deltoid contributes over 60%.
13
Although debated, the relative contribution of the supraspina-
tus to overall abduction of the shoulder has more recently been
shown to be responsible for between 19% and 33% of the total
abduction force generated at the shoulder.
30
Its length-tension
curve demonstrates maximum force at about 30 degrees of eleva-
tion.
5
In selective nerve block studies, the infraspinatus and
teres minor muscles have been found responsible for as much as
60% and 45% of the external rotation force that can be gener-
ated at the shoulder, respectively.
13
The subscapularis muscle is
the only primary internal rotator of the shoulder and as such
is responsible for most of the force in that movement.
Mechanical properties of articular cartilage
and ligaments
When considering shoulder biomechanics, it is important to
understand the mechanical behavior of the soft tissues (namely
ligaments and cartilage) associated with the glenohumeral joint,
the subject of various experimental techniques (Table 5b.2).
Tests of the mechanical properties of glenohumeral articular
cartilage have included both indentation
44
and tensile testing.
70
On average, the aggregate modulus for glenohumeral joint artic-
ular cartilage ranges from roughly 0.5 to 0.9 MPa.
44
Compressive
and shear properties of articular cartilage are important because
of the nature of their role in dynamic articulating surfaces.
Partly because ligaments are anisotropic, in that they have
different properties in the longitudinal and transverse directions,
and partly because their primary function is joint stabilization
typically through tensile loading, the most common method of
Table 5b.2 Mechanical properties of some key
glenohumeral ligaments
Ultimate Elastic
Failure Stiffness stress modulus
Ligament load (N) (N/mm) (MPa) (MPa)
Superior 101.9
11
17.4
11

glenohumeral
Inferior 5.2, 5.5, 5.6* 38.7, 30.3,
glenohumeral 41.9*
Coracohumeral 359.8
11
36.7
11

*Values are for superior, anterior, and posterior regions, respectively.
8
obtaining mechanical properties is the quasistatic tensile test.
However, more sophisticated methods have enabled precise
two-dimensional analysis of the glenohumeral joint. In situ
strain fields in the anteroinferior shoulder capsule have been
quantified in this way using stereoradiogrammetry, showing that
strains are generally higher on the glenoid side of the capsule
than on the humeral side.
35,37
All biologic soft tissues demonstrate both nonlinear and
viscoelastic mechanical behavior under loading. The nonlinear-
ity is characterized initially by a relatively large increase in
elongation with respect to load (Fig. 5b.7). In tensile testing,
this toe region represents the straightening and aligning of
collagen fibers in the longitudinal axis, that is, the direction of
loading. This is followed by a linear region, over which the
mechanical properties such as stiffness are typically evaluated.
The ensuing region of nonlinear yield culminates with the failure
of the specimen.
In addition to behaving nonlinearly, soft tissues are also
considered viscoelastic due to the rate dependence of their
mechanical properties. When loaded rapidly, a ligament tends to
be stiffer than when loaded at a lower rate. IGHL regions have
been shown to have up to 62% increased modulus when loaded
an order of magnitude more rapidly.
44
A phenomenon associ-
ated with soft tissue viscoelasticity is the hysteresis effect. When
a ligament is cyclically loaded and returned to its resting state, the
load-deformation response shifts until equilibrium is eventually
reached after 10-20 cycles.
38
For this reason, biomechanical testing
should begin with a period of preconditioning in which the
specimen is cyclically loaded within its normal physiologic range.
Although biomechanical studies demonstrated that soft
tissue properties change as a function of age
38
and epidemiology
indicates that shoulder and upper limb disorders tend to arise
over time,
34
age has not shown a consistently strong association
with shoulder tendonitis in the workplace environment. This
is due partly to older workers often leaving their jobs because
of the injury, resulting in survivor bias.
23
Animal models
Although cadavers have proven beneficial in experimental
biomechanics research, certain important questions cannot be
Toe region
Strain
Linear region Yield/failure
S
t
r
e
s
s
Figure 5b.7 Typical tensile test of a ligament, showing the toe, linear,
and yield/failure regions.
addressed by testing them. Recently, animal models have gath-
ered significant interest and use to address questions about
the biomechanics of the shoulder and its injuries. The most
fundamental issue that must be addressed when selecting any
animal model is its biofidelity with respect to the body region
of interest.
For the shoulder, several animal models have been used in
studying tendon and rotator cuff injury and repair. New Zealand
white rabbits, for example, have been used to study muscle heal-
ing characteristics after supraspinatus tendon reattachment.
39,66
Other works have investigated rotator cuff repair both in vitro
and in vivo using infraspinatus tendons of sheep.
18,19
Soslowsky et al
59
set out to identify an effective animal model
for studying rotator cuff injuries by examining anatomic charac-
teristics of the shoulder in several different species. In an analy-
sis involving 34 criteria applied to 37 animals, the rat emerged as
the only model to satisfy all criteria while still being practical for
experimental research. The most distinguishing characteristic
that makes the anatomy of the rat shoulder comparable with that
of a human is the position of the acromion and its associated
enclosed arch in relation to the supraspinatus tendon.
59
Sprague-
Dawley rats have since been used effectively in numerous inves-
tigations into the roles of overuse and extrinsic factors in rotator
cuff injuries. In the laboratory setting, overuse activity has
produced a reproducible injury in the rat shoulder comparable
with that seen clinically in the rotator cuff.
61
Injuries stemming
from overuse in combination with extrinsic compression have
resulted in relatively high maximum stresses and elastic moduli
when compared with each of the two factors alone, indicating
that rotator cuff tendinosis is not typically attributable to a
single factor.
62
Prevention of disability through ergonomics
Three of the most prominent risk factors to emerge from studies
of workplace ergonomics are static or extreme posture,
25,51
cycli-
cal occupational motions,
16,21
and external loading.
16,47
The risk
of shoulder disorder has been reported to be two to three times
higher in occupations requiring abduction or flexion beyond
90 degrees for at least 10% of the time performing the task.
51
This combination of awkward shoulder posture and long time
periods has been identified as a key risk factor for disorders.
56
The occurrence of shoulder tendinitis has been found to be two
to three times higher in workers with highly repetitive or cyclical
work tasks involving the upper limbs.
16
External hand loads
in combination with humeral abduction have been linked to
increased rotator cuff muscle pressure, which can have detrimen-
tal effects on the shoulder.
47
Conversely, when an occupation
does not require appreciable loading, the risk of shoulder ten-
dinitis is lower.
16
With sufficient effort focused on these issues in
the workplace through improved ergonomic conditions, resulting
shoulder disorders may be appreciably reduced.
THE ELBOW
Anatomic considerations
Complex in its articular geometry, the elbow is an important link
in the lever arm chain of the upper extremity that facilitates a
broad range of motion, the absence of which causes significant
functional impairment. A working knowledge of the elbows
anatomy is thus important in any effort to understand the
biomechanics at this articulation. The elbow is a trochleo-
ginglymoid joint composed of three bones; the distal humerus
and the proximal ulna and radius (Fig. 5b.8). The three articula-
tions at the elbow are the ulnohumeral, radiohumeral, and
radioulnar joints.
Articulations
Ulnohumeral Joint As the metaphyseal bone of the distal
humerus flares out distally, it forms two supracondylar regions
that end in medial and lateral epicondyles. These epicondyles
flank two odd-shaped asymmetric condyles. The condyles
compose the distal articular surface of the humerus: the trochlea
medially and the capitellum laterally. The ulnohumeral joint is
essentially a hinge governed by the intimate matching geometry
of the trochlea and proximal ulna. The most constrained portion
of the elbow joint, this articulation allows only flexion and
extension. On the humeral side, the trochlea resembles a spool
of thread with broad ends (of which the medial is larger) that
converge into a narrow trochlear groove. In the frontal plane
the trochlea has approximately 6 degrees of valgus tilt that helps
dictate the carrying angle of the normal elbow. There are two
depressions on the distal humerus that participate in the ulno-
humeral joint as well: the coronoid and olecranon fossae. As
the joint goes through flexion and extension, the olecranon and
coronoid fossae accommodate their similarly named processes
on the proximal ulna.
The proximal ulna is composed of two arced processesthe
olecranon and coronoidseparated from each other anteriorly
by the greater and lesser sigmoid notches. A lateral indentation
in the lesser sigmoid notch, the radial notch, provides articula-
tion with the proximal radius. Viewed laterally, the proximal
ulna resembles a claw that tightly grasps the trochlea of the
distal humerus. The olecranon is a large posterior bony process
that provides the posterior articulation for the ulnohumeral joint,
prevents posterior displacement of the humerus, and serves as
the site of attachment for the triceps tendon. Anteriorly, the
coronoid provides the anterior articular surface of the joint,
prevents anterior translation of the humerus, and serves as the
site for the distal insertion of the brachialis muscle.
Although strong transverse and oblique fibers do exist, the
capsule of the elbow is generally weak and reinforced primarily
by strong ligaments medially and laterally that stabilize the joint
against varus and valgus forces (Fig. 5b.8b). On the medial side
of the elbow, the medial collateral ligament (MCL) (often
referred to as the ulnar collateral ligament) has a transverse
Chapter 5b The elbow 163
Ulnar collateral ligament
Annular ligament
C
Humerus
Medial epicondyle
Capitulum
Trochlea
Head
Neck
Tuberosity
Radius
Ulna
Tuberosity
Coronoid process
Trochlear notch
Olecranun
B
Medial
Lateral
Condyle
Lateral
supracondylar crest
Radial fossa
Lateral epicondyle
Capitulum
Head
Neck
Tuberosity
Radius
Humerus
Medial
supracondylar crest
Coronoid
fossa
Medial epicondyle
Trochlea
Coronoid
process
Radial notch of ulna
Tuberosity
Ulna
{
A
Figure 5b.8 Bones of the elbow, anterior (A) and medial (B) views. The orientation of the three components of the medial collateral ligament
include the anterior, posterior, and transverse bundles.
ligament and an anterior and posterior bundle. Laterally, the
radial collateral ligament complex is composed of the annular
ligament, radial collateral ligament proper, and lateral ulnar
collateral ligament (LUCL). The annular ligament is a strong ring
of tissue that loops around the radial head to hold it against
the proximal ulna at the proximal radioulnar joint. The radial
collateral ligament extends from the lateral epicondyle to the
annular ligament and is taut throughout most of the normal
range of motion at the elbow. Invariably present, the LUCL
extends from the lateral epicondyle to the supinator crest on the
proximal ulna.
Radiohumeral Joint The medial condyle of the distal humerus,
the capitellum (l. little head), is spherical and covered by articular
cartilage. At the radiocapitellar joint it articulates with the cylin-
drical head of the radius. The radiocapitellar joint allows flexion-
extension and pronation-supination and also undergoes varus
and valgus moments. As the forearm rotates into either pronation
or supination, the radial head spins underneath the capitellum.
Radioulnar Joint The radial head is bound to the ulna by the
annular ligament and, due to its location, acts as a primary
restraint to valgus force. The proximal radioulnar joint allows
pronation and supination. Like the radiohumeral and ulnohumeral
joints, this joint is enveloped in the elbow capsule.
Muscles
The muscles acting on the elbow play defined roles in facilitating
its motion. In general, muscles crossing the elbow on the ante-
rior surface of the cubital fossa are elbow flexors, whereas those
located posteriorly function to extend the elbow. As described
in the shoulder section above, the biceps muscle crosses both
the shoulder and the elbow joints. Its function at the elbow is to
flex the extended elbow and supinate the flexed forearm, as in
tightening a screw with the right hand. Like the biceps, the
brachioradialis and brachialis muscles flex the elbow. Posteriorly
on the elbow is the triceps brachii muscle, its primary extensor.
Composed of a medial lateral and long head, the muscle extends
the entire length of the posterior brachium to insert as a thick
tendon on the olecranon process of the ulna. Adjacent to the
triceps insertion is a small triangularly shaped muscle called
the anconeus that is minimally involved in forearm extension. The
epicondyles of the distal humerus provide the origin for a num-
ber of forearm muscles that act mostly on the wrist. Table 5b.3
describes the muscles of the arm.
Biomechanics of the elbow
Kinematics
In terms of spatial motion, the elbow is considered to have two
degrees of freedom, flexion/extension and supination/pronation.
Flexion/extension is essentially a hinge-like motion that occurs
at the ulnohumeral joint. This motion defines the carrying angle,
that formed by the ulna and the humerus. The rotational axis
for flexion/extension is formed by the trochlea and capitellum.
The normal range of motion in flexion, from 0 to 150 degrees, is
restricted by bony impingement of the radial head and fossa,
impact between the coronoid process and fossa, and muscular
tension from the triceps.
2
Extension is limited by the impinge-
ment of the olecranon process on the olecranon fossa and ten-
sion of the anterior and medial ligaments and flexor muscles.
31
For supination/pronation, the axis of rotation passes through
the distal ulna and the center of the radial head.
2
The elbow is
normally capable of approximately 75 degrees of pronation and
85 degrees of supination, or 160 degrees of total motion, limited
primarily by muscles and secondarily by ligaments.
2
Constraint
In addition to the aforementioned stability afforded by the
unique topography of the distal humerus and proximal ulna,
additional constraint is provided by the elbow capsule and the
periarticular ligaments.
3,45
At the elbow, the medial and lateral
ligamentous complexes provide most of the additional stability
to the bony configuration. On the medial side of the elbow is
the MCL. Cadaveric studies have determined that the anterior
band of the MCL is the most important section of the ligament
because it is the primary stabilizer against a valgus force.
42
Table 5b.3 Muscles of the arm
Muscle Origin Insertion Innervation Action
Biceps brachii Short head: coracoid process of scapula Tuberosity of the radius and Musculocutaneous n. Forearm flexion, supination of
Long head: supraglenoid tubercle of scapula forearm via bicipital aponeurosis (C5-C6) flexed forearm
Brachialis Distal one half of anterior humerus Coronoid process and tuberosity Musculocutaneous n. Forearm flexion
of ulna (C5-C6)
Coracobrachialis Tip of coracoid process Middle third of medial surface Musculocutaneous n. Flexes and adducts humerus
of humerus (C5-C7)
Triceps brachii Long head: infraglenoid tubercle Proximal olecranon process Radial n. (C6-C8) Extends forearm
Lateral head: posterior surface of humerus
superior to spiral groove
Medial head: posterior surface of humerus
inferior to spiral groove
Anconeus Lateral epicondyle of humerus Lateral surface of olecranon Radial n. (C7-C8, T1) Assists triceps in forearm
extension
n., nerve.
Clinically, this becomes particularly relevant when the radial
head (a secondary valgus stabilizer) is no longer functioning
(e.g., due to fracture).
The lateral collateral ligamentous complex functions mostly
as a varus stabilizer of the elbow. The major component of
the radial collateral ligament complex contributing stability to
varus and rotatory stability of the elbow is the LUCL.
2
Overall,
the LUCL specifically is responsible for most of the lateral sta-
bilization.
2
In addition to holding the radius in the proximal
radioulnar joint, the annular ligament also provides some stability
against varus and valgus stress.
55
Kinetics
Contact in the elbow is typically described with respect to the
ulnohumeral joint. The three most common methods of contact
measurement in the elbow are silicone casting, cartilage staining,
and Fugi Prescale film. Having evaluated all three techniques,
Stormont et al
64
identified silicone casting as the optimal method
for studying elbow contact. In a study using a wax casting
technique,
20
contact was reported to be concentrated on the
medial part of the lower trochlear notch with the elbow in full
extension. At 90 degrees of flexion, the contact appeared pre-
dominantly as a band extending from the lower medial to upper
lateral trochlear notch. At full flexion, the band of contact area
increased, and contact between the radial head and capitulum
became more pronounced.
20
It was noted in a different study
that with increased external load, contact area increased and its
location became increasingly lateral.
64
Although experimentally
difficult on curved articulations, the use of Fugi Prescale film
provides measurements of contact pressure as well as area.
Like the shoulder, the mechanical behavior of elbow liga-
ments is nonlinear and viscoelastic, although there is substan-
tially less information available. Properties for the medial and
radial collateral ligamentous complexes, however, have been
reported.
52
The radial collateral ligament is reported to have
a mean ultimate stress of 15.9 MPa and elastic modulus of
54.3 MPa. The MCL has been found to be stronger and less
elastic, with ultimate stresses of 20.7 and 19.2 MPa and elastic
moduli of 117.8 and 96.8 MPa for the anterior and posterior
bundles, respectively.
In the workplace, flexion/extension is typically involved
in lifting tasks, whereas supination/pronation in combination
with force exertion has been cited as a risk factor for medial
and lateral epicondylitis in tasks involving repeated twisting
motions.
21
As with the shoulder, it has been shown that workers
in high-repetition jobs are two to three times more likely to develop
conditions such as elbow tendinitis than those performing
low-repetition tasks.
34
NOVEL DEVELOPMENTS AND
FUTURE DIRECTIONS
An important area that is gaining momentum in orthopedic
biomechanics is in the field of tissue engineering, which strives
to combine biologic and mechanical elements. Specifically, the
concept of functional tissue engineering mandates consideration
of mechanical properties and functional capabilities when dealing
with tissues that are structurally vital.
12
In particular, functional
tissue engineering approaches are making significant strides toward
improving the healing response of injured tissues such as the
rotator cuff or in creating replacement structures such as for
ligaments and joints. Investigators have begun using resorbable
tissue scaffolds in the hope of regenerating new tendon. Using
materials like porcine small intestine submucosa, human dermis,
and woven starch fabrics, some centers have documented
encouraging results in engineering new tissue growth. Advances
in these areas will likely yield significant benefit to the patient
population in the near future.
The use of in vivo techniques and measurements in lieu of
cadaveric investigations is another developing trend. In vivo meas-
urements of loading and motion in both normal and abnormal
states will further our understanding of the mechanics of the shoul-
der and elbow joints. Noninvasive techniques have begun to play
a more important role in enhancing our understanding of upper
extremity biomechanics. Together with three-dimensional recon-
structed computer-aided tomograms, some investigators have used
in vivo fluoroscopic imaging of the shoulder and elbow to gain
exciting new insight into their kinematics. Using these techniques,
they have gained a more comprehensive appreciation for the load-
ing, contact area, and dynamic motion at these articulations. This
information has helped in the development of better total joint
arthroplasties. Ongoing work is making use also of magnetic reso-
nance imaging to measure tendon strain fields in the shoulder.
Another area that has seen recent development and is likely
poised for significant advancement is in the use of computer
models of the shoulder complex. Based on original work by
both Hgfors et al
26,27
and van der Helm,
67
efforts to combine
finite element and three-dimensional modeling have yielded new
methodologies for investigating the shoulder. Using a six-degree-
of-freedom electromagnetic tracking device, investigators have
obtained complete kinematic descriptions of shoulder motion.
40
Additionally, with these three-dimensional models, investigators
have been able to estimate muscle attachment sites and reliably
apply them to geometric bone models.
32
As the horizon for
new advances in orthopedic bioengineering broadens, we hope
to continue to find even more efficacious applications toward
the prevention and treatment of injury and disability at the
shoulder and elbow.
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When occupational activity-related pain is the chief complaint,
the usual questions as to the location, timing, and character of
the pain need to be supplemented by a detailed work history.
Exploration into the exact nature of the task and how often it
is performed is necessary to further elucidate occupational risk
factors that can predispose to or aggravate the current condition.
How often and how quickly the task is carried out should be
noted. Repetitive work, especially when combined with high force
demands, has been associated with shoulder tendinitis.
4
Other
work-related risk factors include high force, awkward joint posture,
direct pressure, vibration, and repetitive overhead activities.
21
A history with documentation of prior claims, time off
work, and litigation in process constitutes valuable information
because secondary gain can play a significant role in the prog-
nosis. Just as important as the task itself is the mechanical and
psychologic environment in which it is performed. In addition
to the degree of stress involved, the presence of a draft, the need
to work at a height, the positioning of equipment/tools, and
the use of gloves may all play a role in the multifactorial etiol-
ogy of repetitive strain disorders. Consideration of how the pres-
ent condition affects recreation and activities of daily living also
assists in determining the severity of the problem.
Localized pain that is intense enough to disrupt sleep and
cause limitation of simple overhead activities is most commonly
due to rotator cuff pathology. Infection, arthritis, and frozen
shoulder syndrome, however, can less frequently be manifested
in a similar manner. Pain on carrying heavy packages at the side
or when pushing a revolving door open may be more indicative
of instability of the glenohumeral joint.
Patients should be questioned with respect to previous injuries
and any preexisting conditions that may have predisposed them
to the current problem. If an acute injury is reported, details of
its mechanism and the position of the extremity at the time force
was applied should be ascertained. In the case of a fall, the
height, the type of surface onto which the patient fell, and the
body part that struck first should be recorded. Feelings of sub-
luxation or crepitus at the time of injury with an inability to
continue working secondary to immediate pain attest to the
severity. In addition, symptoms of numbness or paraesthesia
may accompany episodes of instability. The mechanism of ante-
rior shoulder dislocation is usually the result of forced abduction
and external rotation of the shoulder, whereas direct trauma is
more likely to cause contusions or fractures. A fall onto or direct
blow to the top of the shoulder often results in varying degrees
of acromioclavicular injury, whereas falls onto the outstretched
hand can easily result in proximal humeral fractures.
For any injury or joint disorder, treatments undertaken to date
must be ascertained. These include previous physician consults,
medications, physiotherapy, splints, or joint injections. In the shoul-
der, multiple steroid injections in the subacromial space may lead to
rotator cuff degeneration and tearing.
26
Finally, a careful past med-
ical history and functional assessment must be obtained. Multiple
joint pains may suggest rheumatologic disease or referred pain.
Physical examination
Even with the most thorough history, the physician may or may
not have a clear sense of the underlying problem. A systematic
Evaluation of the
Shoulder and Elbow
Derek Plausinis and Joseph D. Zuckerman
Coordinated movement of the shoulder and elbow is essential to
position the hand in space. Symptoms related to the shoulder
and elbow are often vague and clinically difficult to diagnose.
Numerous associated musculoskeletal disorders such as tendini-
tis and nerve entrapment syndromes have been found to be
related to repetitive and forceful use of the upper extremity in
a wide variety of occupations.
4
Because symptoms may overlap,
it is important to distinguish referred pain from the cervical spine
or adjacent joints from that arising locally. Sound knowledge of
local anatomy and appreciation of the salient features of the
history and physical examination are crucial to the formulation
of an accurate diagnosis, treatment regimen, and plan for pre-
vention, especially with regard to work-related injuries.
THE SHOULDER
History
Complaints related to the upper extremity must be approached in
an organized methodical manner, with care taken to not focus
too quickly on a specific complaint so as to avoid missing a more
generalized or related condition. At the initial assessment, identi-
fication of personal and work-related risk factors is essential. The
patients age, hand dominance, occupation, and chief complaint
should begin every history because these are the major contribu-
tors to the establishment of an accurate diagnosis. Age and nature
of the complaint can be very directive in identifying the underly-
ing shoulder disorder. A 40-year-old carpenters complaint of pain
in the overhead position, for example, indicates to the physician
to evaluate further the possibility of impingement and rotator
cuff pathology, as opposed to a 20-year-old gymnasts complaint
that the shoulder slips out in the abducted and externally
rotated position, which suggests ligamentous instability.
Symptoms of pain, instability, and loss of motion account
for most complaints about the shoulder. Noting maneuvers that
provoke pain, presence of night pain, radiation of symptoms,
and neck and opposite shoulder pain can aid in differentiating
between referred pain and local pathology. Bilateral shoulder
pain that is worsened by hyperextension or rotation of the neck
but not by glenohumeral motion is due most often to cervical
spine pathology as opposed to an intrinsic shoulder disorder.
The physician must also ask about the presence of any extremity
weakness, radiating pain, or paraesthesia. The distribution of neu-
rologic symptoms assists in differentiating cervical radiculopathy
from myelopathy or brachial neuritis.
C HA P T E R
5c
meticulous approach to the physical examination is therefore
required to avoid missing subtle findings and arriving at a diag-
nosis that is inaccurate or incomplete. A summary of the key
elements of the shoulder physical examination is provided in
Table 5c.1. Note that evaluation of all potential shoulder prob-
lems must include a thorough examination of the cervical spine.
Inspection occurs with the patient sitting or standing and
appropriately gowned to expose the shoulder entirely. The shoul-
der should be examined for signs of asymmetry caused by
muscle wasting, soft tissue swelling, or bone or articular incon-
gruities and a comparison made with the unaffected side. Muscle
spasm involving the trapezius or paracervical muscles may
cause asymmetry and may be related to cervical root pathology,
8
whereas muscle fatigue may affect shoulder posture and kinemat-
ics.
9
Deltoid atrophy may be associated with general disuse of
the shoulder or related to axillary nerve pathology; best noted
from an anterior vantage point, it is characterized by squaring
off of the involved shoulder (Fig. 5c.1). Atrophy of the
supraspinatus or infraspinatus muscles is best visualized from
behind (Fig. 5c.2). Most commonly seen in association with
Chapter 5c Evaluation of the shoulder and elbow 168
Figure 5c.2 Supraspinatus and infraspinatus atrophy noted from
behind; the atrophy was secondary to a long-standing rotator cuff tear.
Table 5c.1 Summary approach to shoulder physical
examination
Cervical spine examination
Neurovascular assessment
Shoulder examination
Inspection
Palpation
Active and passive range of motion
Special tests
Impingement
Hawkins test
Neers test
Painful arc
Rotator cuff muscles
Supraspinatus
Infraspinatus and teres minor
Subscapularis
Biceps tendon
Check for rupture
Speeds test
Yergasons test
Stability tests
Anterior
Posterior
Inferior and generalized laxity
AC joint assessment
Local tenderness
Cross-body adduction
Injection tests
AC joint
Subacromial space
Glenohumeral joint
AC, acromioclavicular.
Note: see text for detailed description of examination maneuvers.
rotator cuff tears, this may be related also to supraspinatus nerve
entrapment neuropathy or C5 nerve root pathology. Prominence
of the clavicle may suggest clavicle fracture or malunion as well
as acromioclavicular joint dislocations (Fig. 5c.3). Swelling is
unusual but may be seen in cases of subacromial bursitis or
extravasation of synovial fluid in massive rotator cuff tears.
Posterior dimpling or a sulcus may suggest anterior shoulder
dislocation.
Figure 5c.1 Severe axillary nerve palsy manifested as deltoid
atrophy, squaring off of the shoulder, and inferior subluxation of the
humeral head.
The next step in a comprehensive examination of the shoulder
is palpation of the bony and soft tissue elements. Tenderness or
crepitus about the clavicle suggests fracture or nonunion, partic-
ularly if consistent with details of the history. Acromioclavicular
joint tenderness is found in cases of arthritis and may be seen in
those whose occupations require carrying heavy loads on their
shoulders like lumber or postal bags
21
or in the presence of insta-
bility secondary to traumatic ligamentous disruption. Tenderness
on palpation over various anatomic landmarks can provide impor-
tant clues leading to a diagnosis: Tenderness of the anterior of
the acromion may be a subtle indicator of rotator cuff impinge-
ment; tenderness about the greater tuberosity may be seen in
cases of rotator cuff tears, supraspinatus tendinitis, or fracture;
tenderness over the bicipital groove, which is found between
the greater and lesser tuberosities, is suggestive of bicipital ten-
dinitis; and tenderness over the posterior joint line beneath the
posterior of the acromion may represent glenohumeral arthritis.
Anterior joint or capsular tenderness is more representative of
soft tissue injury after anterior shoulder dislocation or sub-
luxation.
8
A nonspecific indicator of inflammation, local
warmth is seen in conditions such as inflammatory arthritides
or infection. Anesthesia or hypoesthesia in the dermatome over-
lying the middle deltoid suggests injury to the axillary nerve
from traction, compression, or demyelination.
Both active and passive joint motion must be assessed. It
is important to understand the two basic components of shoul-
der elevation: glenohumeral and scapulothoracic. In the first
30 degrees of elevation in the scapular plane, motion occurs
mostly at the glenohumeral joint. As the arm is elevated further,
more scapulothoracic motion occurs with an equal contribution
of glenohumeral and scapulothoracic movement in the last
60 degrees of elevation. In elevation there is a 2:1 ratio of gleno-
humeral to scapulothoracic motion overall.
12
To assess the rela-
tive contributions of each, the scapula should be stabilized by
holding the inferior scapular angle. Adhesions or rotator cuff
derangement likely alters the normal fluid pattern of gleno-
humeral motion, and a greater proportion of the arc of motion
becomes scapulothoracic.
Chapter 5c The shoulder 169
Figure 5c.4 External rotation of the glenohumeral joint is assessed
with the patient supine to prevent torso rotation. The elbow is flexed to
90 degrees with the arm at the side.
Figure 5c.3 Acromioclavicular separation with complete loss of
articulation of the joint surfaces and prominence of the distal end of
the clavicle.
The American Shoulder and Elbow Surgeons has recom-
mended that four planes of shoulder motion be assessed in all
patients: total forward elevation, external rotation with the elbow
at the side, external rotation with the arm abducted 90 degrees,
and internal rotation behind the back.
22
Active and passive motion
for both shoulders should be recorded. Abduction and internal
rotation are best examined with the patient sitting upright on the
examination table. Forward elevation and external rotation can
most accurately be examined with the patient both upright and
supine to ensure that compensatory movements of the spine are
eliminated. A limited active arc of motion may have a mus-
culotendinous or neurologic etiology, or it may be related to
pain. Limited passive motion suggests a mechanical block as
in adhesive capsulitis, malunion of fractures, loose bodies, or
glenohumeral arthritis. When assessing forward elevation, the
practitioner should view the patient from a lateral position and
reference the angle of the arm with the posterior thorax. External
rotation, both active and passive, is best assessed with the arm
at the side and the elbow flexed 90 degrees (Fig. 5c.4). A deficiency
in active external rotation generally indicates neurologic or rota-
tor cuff derangement, whereas one in both active and passive
external rotation may be seen in adhesive capsulitis or in patients
with mechanical blocks such as locked posterior dislocations.
Testing external rotation with the arm abducted 90 degrees may
be helpful, particularly in patients performing repetitive over-
head activities such as throwing or welding. In this position,
symptoms suggestive of capsulolabral deficiencies, greater
tuberosity pathology, and instability may be elicited. Internal
rotation is generally tested with the patient sitting upright. The
patient is asked to reach around the back while internally rotat-
ing (and slightly extending) the shoulder so as to record the level
reached by the outstretched thumb. This is commonly docu-
mented as the buttock, sacrum, iliac crest, and exact lumbar
or thoracic spinous process reached. Generally, active and pas-
sive range of motion in this plane is similar, with limitations
again suggestive of subacromial pathology such as rotator cuff
derangement or a frozen shoulder.
Muscle strength testing is essential to assess the competence
of the musculotendinous complexes about the shoulder and to
identify possible peripheral or central neuropathology such as
peripheral compressive neuropathy or cervical stenosis. In this
regard, a thorough understanding of the structure of the brachial
plexus and innervation patterns more peripherally is critical.
Clearly, a suggestion of cervical pathology stimulates a more
thorough neurologic examination. Muscle strength should be
recorded using the universal system of grading on a scale from
0 to 5, with the opposite and presumably normal limb used
as the control for comparison (Table 5c.2). It is important to
realize that in the presence of pain, the accuracy of motor
strength recording may be called into question.
The primary motor functionsforward flexion, abduction,
and external and internal rotationare tested by resisting the
particular plane of motion. Forward flexion is primarily the role
of the anterior head of the deltoid muscle (axillary nerve, C5-C6)
with secondary flexors, including the biceps and coracobrachialis
muscles (musculocutaneous nerve, C5-C7), and the clavicular
portion of the pectoralis major muscle (lateral pectoral nerve,
C5-C6). Abduction tests the strength of both the middle third
of the deltoid muscle (axillary nerve, C5-C6) and the supraspina-
tus muscle (suprascapular nerve, C5). Finally, the presence of
scapular winging should be noted, indicating dysfunction of the
serratus anterior (long thoracic nerve, C5-C7) or the trapezius
(spinal accessory nerve). Scapular winging may be demonstrated
by inspecting from behind while asking the patient to push against
a wall.
For assessing the rotator cuff, the key clinical features are
muscle strength and pain. Whereas weakness alone may suggest
a compressive neuropathy, that accompanied by pain suggests
rotator cuff pathology. Before formal cuff muscle testing, the
presence of any muscular atrophy is first noted (Fig. 5c.1). The
greater tuberosity is palpated for tenderness or defect at the site
of insertion of the supraspinatus, and the shoulder is passively
flexed and extended while palpating for subacromial crepitus.
The strength of the supraspinatus muscle may be isolated by
elevating the arm 90 degrees, maximally pronating the forearm
with the thumb down, and applying a downward force on the
patients arm.
24
The supraspinatus is affected in most rotator cuff
tears, and when extension into the infraspinatus tendon occurs,
external rotation may be weak or painful.
External rotation strength with the elbow at the side assesses
principally the infraspinatus muscle (suprascapular nerve, C5-C6)
and teres minor muscle (axillary nerve, C5-C6). Large rotator
Table 5c.2 Muscle grading
Muscle gradations Description
5 (normal) Complete ROM against gravity with full resistance
4 (good) Complete ROM against gravity with some resistance
3 (fair) Complete ROM against gravity
2 (poor) Complete ROM with gravity eliminated
1 (trace) Evidence of muscle contraction; no joint motion
0 (absent) No contractility
ROM, range of motion.
cuff tears often produce a discrepancy between active and passive
motion. The dropping sign is demonstrated by grasping the
forearm with the elbow flexed and held at the side and passively
externally rotating the shoulder 45 degrees. The patient is asked
to resist a force in external rotation as the forearm is released.
If the patient is unable to hold the arm in this position and the
forearm drops to a neutral position, then the dropping sign is
positive for infraspinatus weakness.
9
Further extension of a rota-
tor cuff tear into the teres minor can be suggested by external
rotation weakness in abduction. This is tested by supporting
the patients arm at 90 degrees of elevation in the scapular plane
and then asking the patient to externally rotate against resistance
(Fig. 5c.5). If the patient cannot externally rotate, then a horn-
blowers sign is present,
27
indicating extension of a tear into the
teres minor. This sign can be functionally illustrated by asking
the patient to bring the hand to the mouth; patients with infra-
spinatus and teres minor cuff weakness will abduct the arm to
accommodate for inability to externally rotate.
The subscapularis cannot be isolated by testing internal
rotation strength with the arm at the side but rather requires the
lift-off test,
6
which involves asking the patient to place his or
her hand behind the back at the lumbosacral junction and then
lift the hand off. Inability to perform a lift-off suggests sub-
scapularis rupture; many patients with shoulder stiffness, how-
ever, are unable to perform this maneuver. The examiner must
pay attention to the elbow during the lift-off test, because
patients with subscapularis deficiency may give the false impres-
sion of being able to lift off by extending the elbow. When
patients have limited internal rotation and the ability to perform
the lift-off test is compromised, the subscapularis may be tested
with the belly press,
5
which involves asking the patient to place
his or her hand on the abdomen and then bring his or her elbow
forward to the level of the hand. Patients with subscapularis
insufficiency will keep their elbow at the side with the wrist
flexed and will be unable to effectively bring the elbow forward.
Figure 5c.5 To test for teres minor involvement in rotator cuff
disorders, support the patients arm at 90 degrees of elevation in the
scapular plane and ask the patient to externally rotate against
resistance. The inability to externally rotate the arm indicates a
positive horn blowers sign.
Several provocative tests can be used to elucidate subacro-
mial impingement, of which two have been classically used. The
Neer impingement sign consists of forced forward elevation of
the arm.
13
Pain is elicited as the inflamed supraspinatus tendon
impinges against the inferior border of the acromion anterior
(Fig. 5c.6). If local anesthetic is administered to the subacromial
space, pain in impingement syndrome is eliminated, which then
confirms a positive impingement test.
13
The impingement sign
becomes much less reliable, however, when there is a limitation
of passive forward elevation. In the Hawkins impingement test,
the arm is forward-flexed 90 degrees and then forcibly internally
rotated. Pain is evoked as the inflamed supraspinatus tendon
is impinged against the coracoacromial ligament. In addition to
these impingement tests, patients with impingement often
demonstrate a painful arc. As the arm is abducted in the
coronal plane, pain occurs between 60 and 100 degrees and is
usually maximal at 90 degrees. Patients may be observed to
rotate the humerus externally in the abducted position to mini-
mize impingement of the greater tuberosity under the acromion.
Assessment of the acromioclavicular joint begins with exami-
nation for local tenderness and swelling. A provocative maneu-
ver for acromioclavicular joint pathology, cross-body adduction,
can be elicited by passively elevating the arm to 90 degrees and
adducting the arm and forearm across the chest. Pain near the
acromioclavicular joint with cross-body adduction indicates
acromioclavicular joint pathology,
3
whereas that in the posterior
shoulder usually results from posterior capsular tightness.
In patients with documented or suspected glenohumeral
instability, anterior instability is the most common clinical
presentation. The simplest clinical maneuver, the apprehension
test, is performed with the patient in the supine position with
the arm abducted 90 degrees. The shoulder is externally rotated
as the patients facial expression is noted. A patients appre-
hension or sense of impending shoulder subluxation or disloca-
tion indicates a positive test. The relocation test can then
be performed with the shoulder at the point of apprehension.
Figure 5c.7 Anterior instability is tested by placing the shoulder in
90 degrees of abduction and external rotation while attempting to level
the humeral head out anteriorly with gentle posterior pressure.
Apprehension and pain are indicative of positive responses.
Figure 5c.6 Positive impingement sign as described by Neer with
forced forward elevation of the arm, causing the supraspinatus to
impinge on the undersurface of the acromion.
A posteriorly directed force is applied to the proximal humerus,
and in cases of instability pain or apprehension is relieved, indi-
cating a positive relocation test.
25
A similar but more provoca-
tive test for anterior instability is to abduct and externally rotate
the shoulder in the upright position. When an anteriorly
directed force is applied to the posterior proximal humerus,
the patient with anterior instability becomes apprehensive or
experiences pain in the shoulder (Fig. 5c.7).
Although less common, posterior instability may be seen
after a traumatic event or in association with a history of seizure
disorder or alcohol abuse. A posterior apprehension test may
be performed by flexing and internally rotating the shoulder and
noting if the patient experiences a sense of instability. To further
assess posterior laxity, an axial load can be applied to the elbow
with the shoulder flexed 90 degrees and in neutral rotation.
This maneuver subluxes the humeral head posteriorly. The exam-
iner then abducts the arm and palpates for the sudden reduction
of the subluxed shoulder.
8
Anterior and posterior capsular laxity may be examined further
by assessing the amount of glenohumeral translation. This may
be difficult to produce on examination without the benefit of
anesthesia but should be assessed in all patients. Humeral head
translations may be tested with the patient sitting upright or
lying supine while the scapula is stabilized with one hand and
the humeral head grasped with the other. Anterior and posterior
translatory loads are applied to evaluate anterior and posterior
instability, respectively. The humeral head normally translates
posteriorly up to 50% of the width of the glenoid, but the shoul-
der does not appreciably translate anteriorly. It is important to
compare these findings with those in the opposite shoulder
because some degree of laxity may be expected even in normal
shoulders.
Patients with inferior instability may have their symptoms
reproduced by applying longitudinal downward traction on
the arm. When the deltoid muscle is relaxed, an inferior sulcus
sign is usually present in affected patients (Fig. 5c.8). Patients
with inferior instability commonly also have anterior and pos-
terior instability, in which case the term multidirectional insta-
bility is used. This condition is usually associated with
generalized hyperlaxity as evidenced by hyperextension of the
elbows and knees or the ability for the patient to bring the
thumb passively to touch the ipsilateral forearm.
Figure 5c.8 Inferior ligamentous laxity exhibited by an inferiorly
subluxed humeral head with downward traction on the humerus with
the arm at the side.
The long head of the biceps is first assessed by examining
for continuity of the tendon. The patient is asked to resist gen-
tle flexion of the elbow, and the upper arm is inspected. An
abrupt change in contour of the biceps muscle proximally that is
asymmetric with the contralateral side, referred to as a Popeye
muscle, indicates rupture of the long head of the biceps. With
an intact biceps tendon, tenderness in the bicipital groove is a
common finding in bicipital tendinitis. As the humerus is exter-
nally rotated, the anterior pain of bicipital tendonitis typically
moves more laterally with the externally rotated bicipital groove.
Common provocative maneuvers for long head of biceps
pain include Yergasons test and Speeds test. Yergasons test con-
sists of actively supinating the forearm against examiner resist-
ance with the elbow flexed 90 degrees. Speeds test involves
forward elevation of the arm against resistance with the elbow
extended and the forearm supinated. If positive, both tests elicit
pain in the region of the bicipital groove. It should be noted
that this diagnosis is often a component of the impingement
syndrome, and controversy exists as to whether it exists as an
isolated entity.
In addition to the detailed neurologic examination outlined
earlier, a careful vascular examination should be performed to
rule out vascular compression in the neck as the source of clau-
dicant shoulder pain, the so-called thoracic outlet syndrome.
Distal pulses should routinely be palpated. Several tests have
a time-honored role in the diagnosis of vascular insufficiency,
perhaps the most commonly used of which is Adsons maneuver
or one of its several modifications. The examiner palpates the
radial pulse and abducts the ipsilateral arm 90 degrees while
extending and externally rotating the shoulder with the patient
turning the head to the opposite side. A diminishing peripheral
pulse signifies proximal compression and indicates a positive
test. It is critical to identify the source of vascular compression,
including an accessory rib, Pancoasts tumor, fibrous bands,
or clavicular malunion, so that proper steps in management may
be taken.
Diagnostic testing
The practitioner generally establishes the diagnosis after a thor-
ough history and comprehensive physical examination. Most
imaging tests are performed to confirm the physicians clinical
impression, but inevitably in some cases the diagnosis remains
unclear and further investigation is warranted.
The mainstay of imaging remains the standard radiograph.
In general, all patients with complaints referable to the shoulder
should receive a routine series of at least three radiographs as
initial screening. This consists of anteroposterior (AP), scapular
lateral, and axillary radiographs of the shoulder with the beam
centered over the glenohumeral joint. When shooting these
radiographs it is important to follow meticulous guidelines and
to keep in mind that the plane of the scapula is rotated anteri-
orly approximately 35 to 40 degrees (Fig. 5c.9). A true AP radi-
ograph in the scapular plane is taken with the posterior aspect
of the affected shoulder against the cassette and the opposite
shoulder rotated anteriorly approximately 40 degrees. The AP
radiograph in internal rotation shows the greater tuberosity
en face, external rotation shows it in profile, and both show
different aspects of the humeral head. In these views the distance
between the humeral head and the acromion process should be
assessed. In cases of massive rotator cuff tears, the normal inter-
space, averaging 10 mm, may diminish as the humeral head
migrates cephalad, and a break in the inferior calcar line may be
seen (Fig. 5c.10).
7
Also considered routine in trauma situations
is the scapular lateral view, in which the scapula is seen tangen-
tially. This is an anterior oblique projection taken with the
patient rotating the involved shoulder 60 degrees toward the
central beam.
7
Its value lies in identifying shoulder dislocations
and fractures of the humeral head or neck or scapula.
In the axillary view, the patient is positioned supine with the
arm abducted. A horizontal x-ray beam is directed in toward
the axilla. This projection visualizes the relationship between the
humeral head, glenoid, coracoid, and acromion (Fig. 5c.11). It is a
key projection for identifying shoulder dislocations and any asso-
ciated anterior glenoid avulsion fractures (bony Bankart lesion) or
posterior impression fractures of the humeral head (Hill-Sachs
lesion) (Fig. 5c.12). The relative position of the anterior aspect of
the acromion with respect to the clavicle should be assessed, par-
ticularly in cases of impingement syndrome. Anterior projection
of the acromion beyond the anterior limits of the clavicle has been
shown to predispose to rotator cuff problems.
28
The outlet view represents a lateral projection into the
subacromial space. It is an ideal projection for assessing the slope
of the acromion, which has been shown to have an impact on
the development of impingement syndrome (Fig. 5c.13). It is
taken with the patient standing and the affected shoulder
rotated 60 degrees toward an x-ray beam angled 10 to 15 degrees
caudad.
7
C
A
B
Figure 5c.9 Technique for obtaining scapular anteroposterior (A), lateral (B), and axillary (C) views of a trauma series required on all patients.
A specialized AP radiograph angled 15 degrees cephalad is a
valuable tool for imaging the distal and middle aspects of the
clavicle and acromioclavicular joint. As such, this projection is
used to assess clavicle fractures, acromioclavicular joint sprains,
arthritis, or spurring (a source of rotator cuff impingement), or
distal clavicle osteolysis (common in weight lifters).
Magnetic resonance imaging (MRI) has become the imaging
modality of choice in most centers for identifying most soft
Figure 5c.10 In the presence of massive rotator cuff tears, a high-
riding humeral head is noted with decreased acromiohumeral distance
and a break in the inferior calcar margin.
H
AC
A
G
C
H
AC
A
G
C
Figure 5c.11 Axillary view of the shoulder, crucial for determining the
position of the humeral head in relation to the glenoid. The labeled
structures are the humeral head (H), glenoid (G), coracoid (C),
acromion (A), and acromioclavicular joint (AC).
Figure 5c.12 Locked posterior dislocation with a humeral head
impression fracture.
Figure 5c.13 Supraspinatus outlet view with a large subacromial
spur, causing impingement.
tissue pathology about the shoulder. Multiaxial images and the
development of newer MRI protocols have enabled more accu-
rate assessments of shoulder pathology. For rotator cuff pathol-
ogy and impingement syndrome, MRI can identify rotator
cuff tendinosis and partial and full thickness tears (Fig. 5c.14).
1
An estimate of rotator cuff tear size can be made, and the pres-
ence of fatty degeneration of the rotator cuff muscles can be
identified. In cases of impingement, MRI can also identify
potential sources of cuff impingement such as an osteophyte
from the undersurface of the acromioclavicular joint, acromio-
clavicular joint hypertrophy, or a downward-beaking acromion
that may be associated with a subacromial spur.
In cases of instability when the diagnosis is unclear, MRI
can be used to detect capsular injury or redundancy as well as
labral tears. Although infrequent, in cases of violent traumatic
anterior shoulder dislocations, the subscapularis tendon may be
torn either directly off its insertion on the lesser tuberosity or
in its mid-substance. In the latter case, MRI potentially shows
retraction at the site of the tear, or in chronic cases calcific
deposits may be seen in the substance of the subscapularis mus-
cle or tendon. The tendon of the long head of the biceps can be
imaged on axial cuts as it sits in the bicipital groove. Absence of
the tendon in this landmark would imply rupture and subsequent
retraction (which should be obvious on clinical examination) or
subluxation, as may be seen in a congenitally shallow bicipital
groove or after trauma. Bicipital tendinitis is often a more prox-
imal phenomenon and is difficult to image by MRI. Finally,
MRI has a role in the diagnosis of osteonecrosis of the humeral
head and should be considered in certain high-risk conditions
such as sickle cell disease, steroid use, or alcohol abuse or in
deep sea divers in the setting of shoulder pain even without
radiographic findings.
Historically regarded as unreliable, ultrasonography has played
an increasing role in rotator cuff diagnoses in recent years. With
newer equipment and experienced ultrasonographers, sensitivi-
ties and specificities of 94% or greater for the detection of full-
thickness tears and 93% or greater for partial-thickness tears
have been reported.
23
Although it has a lower cost than MRI and
is a noninvasive test, the availability of accurate rotator cuff
assessment is limited by the availability of an experienced mus-
culoskeletal ultrasonographer.
A
RT
GT
AC
SS
A
RT
GT
AC
SS
Figure 5c.14 Magnetic resonance image of the right shoulder
revealing a full-thickness rotator cuff tear (RT) with a retracted
supraspinatus tendon (SS) underneath the acromion (A) and
acromioclavicular joint (AC). The greater tuberosity (GT) is also shown.
Figure 5c.15 Arthrogram documenting a full-thickness rotator cuff
tear with dye extravasation into the subacromial space and laterally to
the greater tuberosity.
Although it has largely been replaced by MRI and ultra-
sound, arthrography continues to have a role in the diagnosis of
shoulder disorders. It entails injection of either contrast alone
or contrast followed by the injection of room air into the gleno-
humeral joint. Various x-ray views are then taken to assess differ-
ent shoulder components. The technique has a time-honored
role in the diagnosis of complete rotator cuff tears (Fig. 5c.15).
The arthrogram may be used also to visualize the long head
of the biceps tendon, thereby diagnosing rupture, tenosynovitis,
or subluxation.
Computed tomography (CT) is used primarily to assess bony
pathology further when details are unclear from plain radi-
ographs, as may be seen in cases of recurrent instability with
glenoid or humeral head defects.
Lidocaine injection tests serve a vital role with regard to
problems of the shoulder in that they can be valuable diagnostic
tools when the precise diagnosis is in question. For instance, at
times it may be difficult to localize the source of symptoms to
the acromioclavicular joint, the subacromial space, or the gleno-
humeral joint. In these situations, selective lidocaine injection
can be of obvious benefit. The subacromial space is the most
frequently injected region. Amelioration of symptoms points to
rotator cuff tendinitis or tear as the culprit; conversely, if symp-
toms persist, the source of pain is elsewhere, although the sub-
acromial space may be responsible at least in part. Various
techniques for injection have been described; nevertheless, it is
always important to follow strict sterile technique to minimize
the risk of infection. The subacromial space can be injected
from a lateral approach with relative ease (Fig. 5c.16). Downward
traction may be applied to the arm to help widen the interval
between the humeral head and the acromion. Also a frequent
source of pain, the acromioclavicular joint is easily palpated
between the distal clavicle and the acromion, with a needle
directed from its superior aspect. Often, pathology in this joint
is associated with impingement of the rotator cuff, and selective
injection here may help clarify the severity of the referred pain.
Technetium bone scanning has a limited role in the evaluation
of problems related to the shoulder. However, it may be of use
in the evaluation of adhesive capsulitis or in ruling out occult
infection, tumor, or avascularity in the presence of persistent
symptomatology. Electromyographic and other nerve conduc-
tion studies have a definite role in distinguishing central from
peripheral neuropathy and in investigating the possibility of a
neural basis of muscle wasting or weakness when intrinsic
myotendinous pathology is ruled out.
In suggestive cases, shoulder evaluation may include laboratory
studies, particularly routine blood tests such as a complete blood
count, erythrocyte sedimentation rate, C-reactive protein, rheuma-
toid factor, antinuclear antibody, and blood chemistry analysis,
to exclude inflammatory arthritides or infection. Additionally,
adhesive capsulitis is more likely in diabetic patients, hence
the importance of assessing serum glucose levels. If joint sepsis
or crystal diseases are suspected, the glenohumeral joint can be
aspirated and fluid sent for Gram stain, culture, cell count, and
microscopy for crystals.
THE ELBOW
History
The approach to the history for the patient with an occupational
elbow disorder follows an outline similar to that for a shoulder
disorder. The general content for history of present illness and
occupational history are as outlined previously. Specific com-
plaints arising from elbow pathology with clinical examples are
provided below.
Symptoms related to the elbow usually involve pain or
stiffness. Whereas pain is a common complaint with advanced
elbow arthritis, the early phases of degenerative joint disease in
the elbow usually present with loss of motion as the primary
concern. After any trauma to the elbow, stiffness is also a
common complaint, particularly with a history of prolonged
Figure 5c.17 Lateral view demonstrating a spur off the tip of the
olecranon.
Figure 5c.16 Subacromial lidocaine injection test via a lateral
approach is extremely valuable in the diagnosis of impingement.
immobilization after injury. Elbow stiffness may or may not be
associated with pain, and it is important to delineate whether the
patients primary concern and source of functional impairment
is pain or stiffness.
Degenerative joint disease ultimately results in activity-related
pain, usually first occurring near full extension. Osteoarthritis
may present also with a history of episodic sharp pain in the
elbow and intermittent loss of motion or locking. These mechan-
ical symptoms commonly arise also after a traumatic event to the
elbow and suggest the presence of loose bodies that usually
require surgical removal.
Patients may notice swelling about the elbow joint. A joint
effusion or synovitis is present with some diffuse swelling about
the elbow and is often more apparent clinically in the postero-
lateral aspect. In contrast, olecranon bursitis may present with
a recurrent mass directly over the olecranon. Bone spurs off
the olecranon (Fig. 5c.17) have been associated with olecranon
bursitis (Fig. 5c.18), and the patient may have noticed the devel-
opment of a more prominent olecranon. Olecranon bursitis
may be sterile or septic, and the patient should be questioned as
to a history of fever, erythema, previous attempts at aspiration,
and drainage.
Unlike the shoulder, recurrent instability is an uncommon
problem in the elbow. Stiffness is the usual problem after elbow
dislocation. When present, instability may present as recurrent
episodes of dislocation or more commonly as a sense of elbow
subluxation and pain. In cases of recurrent instability after elbow
trauma, symptoms are most likely to occur from lateral ligament
deficiency and are provoked by activities where a valgus stress is
applied to the elbow with the forearm in supination. The valgus
instability from medial collateral ligament laxity is typically
seen in throwing athletes and very uncommonly as a result of
workplace injury.
Tendinopathy about the elbow is a common problem, usually
presenting as medial or lateral epicondylitis. Patients typically
complain of pain in the region of the flexor or extensor origin
that is aggravated with repetitive active wrist movement. Chronic
tendinitis of the distal biceps tendon is uncommon; however,
ruptures may occur after resisted activity, typically in the domi-
nant arms of men in their forties.
Entrapment neuropathies about the elbow must be consid-
ered also as a possible source of elbow pain and may present
with weakness or sensory changes in the hand and wrist as well.
Lying posterior to the medial epicondyle, the ulnar nerve is prone
to compression and irritation with activities requiring recurrent
elbow flexion or from direct compression over the nerve. In
cases of cubital tunnel syndrome (ulnar nerve entrapment at
the elbow), patients typically complain of sensory changes in
the ring and small fingers. The ulnar nerve lies close to the ulno-
humeral joint and in cases of arthritis can be prone to irritation
from osteophytes and loose bodies.
17
Median and radial nerve
compression at the elbow level may occur also, although less fre-
quently than ulnar nerve entrapment. Patients typically present
with elbow pain, and neurologic symptoms are less common.
19,20
When considering the diagnosis of peripheral nerve entrapment,
the distribution of symptoms and the exacerbating features
are critical to help determine whether the symptoms are truly
originating at the elbow level or whether referred pain from the
shoulder or a cervical radiculopathy may be the underlying cause.
As in the case of shoulder examination, a thorough elbow exam-
ination begins with an evaluation of the cervical spine. Shoulder
and wrist examination must be performed also to rule out
a referred etiology for the current complaint. In addition, the
complete upper extremity examination will reveal any other
disabilities from joints above or below the elbow that may
contribute to the patients functional deficit.
Chapter 5c The elbow 177
Figure 5c.18 Classic appearance of olecranon bursitis. Note the
prominent fluid-filled bursa over the olecranon (compared with a normal
elbow in Fig. 5c.19).
O
E
R
O
E
R
Figure 5c.19 Lateral side of elbow illustrating the palpable bony
landmarks: lateral epicondyles (E), radial head (R), and olecranon (O).
Inspection of the elbow is first undertaken to look for any signs
of inflammation or previous injury. To identify subtle findings,
comparison with the unaffected side is helpful. An elbow effusion
may be clinically apparent by a fullness in the posterolateral aspect,
whereas olecranon bursitis presents with a local mass over the ole-
cranon (Fig. 5c.18). With the elbow in full extension and the fore-
arm in supination, the alignment of the ulna compared with
humerus (carrying angle) is estimated. Despite considerable varia-
tion among individuals, normal values for the carrying angle are
approximately 10 degrees for men and 13 degrees for women.
19
Childhood injuries to the elbow commonly result in alteration of
the carrying angle into either valgus or varus malalignment.
Although excess valgus alignment may lead to ulnar nerve irrita-
tion,
17
varus malalignment, also termed a gunstock deformity, is
usually not associated with any functional deficits.
Palpation of the elbow relies first on establishing the appro-
priate surface anatomy. On the lateral aspect, three important
bony landmarks appear: lateral epicondyle, radial head, and tip
of the olecranon (Fig. 5c.19). The radial head is a bony promi-
nence just distal and slightly inferior to the lateral epicondyle.
The location of the radial head is confirmed by rotating the fore-
arm with the elbow held at 90 degrees of flexion; the rotation of
the radial head on the stationary capitellum is palpable. At the
center of these three bony landmarks (Fig. 5c.19), fullness indi-
cates synovitis or effusion and represents also a safe location for
elbow joint aspiration or injection. The radiocapitellar joint may
be palpated between the radial head and the lateral epicondyles.
While palpating over this region, passive forearm rotation and
passive flexion and extension allow for an assessment of any
crepitus or soft tissue snapping from the radiocapitellar joint.
On the medial side of the elbow, the medial epicondyle and
the olecranon may be identified. In the groove posterior to the
medial epicondyle lies the ulnar nerve, which may be gently
palpated. Medial to the ulnar nerve is the medial aspect of the
ulnohumeral joint. Placing the examining index finger and thumb
on either side of the ulna just distal to the olecranon while the
elbow is gently flexed and extended allows for the assessment of
ulnohumeral joint crepitus and tenderness.
Tendons about the elbow are then systematically palpated.
Each tendon should be palpated for continuity on active con-
traction of the corresponding muscle group. The presence
of local tenderness, pain with resisted activity, and pain with
passive stretch of a tendon suggests tendinopathy. For example,
the common extensor origin is just distal to the lateral epi-
condyle. Local tenderness, pain with resisted active wrist exten-
sion, and pain with passive wrist flexion all suggest a diagnosis
of lateral epicondylitis (tennis elbow). Similarly, pain over the
common flexor-pronator origin just distal to the medial epi-
condyle along with pain with resisted active wrist flexion and
passive wrist extension suggest medial epicondylitis (golfers
elbow). After examining the common flexor and extensor ori-
gins, the triceps tendon is examined. The triceps tendon inserts
into the olecranon, and palpation may reveal a prominent trac-
tion spur (Fig. 5c.17). The distal biceps tendon can then be iden-
tified in the middle of the antecubital fossa just lateral to the
brachial artery. The biceps assists in elbow flexion and is also the
primary muscle responsible for forearm supination. A ruptured
distal biceps tendon (reverse Popeye sign) can be identified by
having the patient perform resisted supination with the elbow
in a flexed position and noting a lack of palpable tendon in
the cubital fossa. Another symptom is a prominent bulge of the
distal aspect of the biceps muscle.
The elbow is then taken through both active and passive
movements so that range of motion can be documented. Any
crepitus from the ulnohumeral or radiocapitellar joints is noted.
In addition to flexion and extension, forearm rotation must also
be documented. Limitation of motion or pain on forearm rota-
tion mandates a detailed wrist examination to rule out any
pathology at the distal radioulnar joint. Normal elbow range of
motion is from full extension (0 degrees) to 145 degrees of flex-
ion. Normal forearm rotation is from 75 degrees of pronation to
85 degrees of supination.
2
For a patient to perform most activities
of daily living, range of motion from 30 degrees to 130 degrees
of flexion and forearm rotation from 50 degrees of pronation to
50 degrees of supination (i.e., 100 degrees of flexion-extension
and a 100-degree arc of forearm rotation) is necessary.
11
Stability testing of the elbow can be challenging, but in the
setting of occupational disorders elbow instability is an infre-
quent finding. One of the challenges of instability testing is that
valgus and varus stability tests require rotationally stabilizing
the humerus. From full extension to 20 degrees of flexion the
collateral ligaments cannot be isolated, because bony contribu-
tions to stability are provided by the seating of the olecranon in
the olecranon fossa. Medial collateral ligament laxity has been
shown to be greatest with the elbow in 20 degrees of flexion and
the forearm pronated.
16
To test the medial collateral ligament,
the elbow is held flexed approximately 20 to 30 degrees with the
forearm pronated and the arm maximally externally rotated as a
valgus stress is applied. The presence of medial-sided pain and
palpable medial joint line opening are signs of medial collateral
pathology. Another test to stress the medial collateral ligaments
is the milking sign performed by fully flexing the patients
elbow and grasping the thumb to apply a valgus stress to the
elbow. The test is positive if medial elbow pain is elicited.
Varus stability is tested also with the elbow at 20 to 30 degrees
of flexion but instead requires maximum internal rotation of the
arm. The examiner can then stand behind the patient to apply
the varus stress and examine the lateral joint line. Recurrent
instability occurs very infrequently after elbow dislocations, and
the specific tests for the lateral ligament complex are well
described.
14
These tests are rarely important, however, in the
setting of occupational elbow disorders.
At elbow level the ulnar, radial, and median nerves may all be
compressed. A detailed assessment of ulnar, radial, and median
motor and sensory function, including inspection of the hand
and forearm for muscle atrophy or fasciculations, should be
performed. The ulnar nerve is palpated behind the medial epi-
condyle and once identified, the elbow can be brought from a
position of extension to flexion to determine whether the ulnar
nerve subluxes or dislocates anteriorly during flexion. Gently
tapping over the nerve may produce paresthesia radiating into
the small finger and ulnar half of the ring finger (Tinels sign
at the cubital tunnel), indicating nerve irritation. A further sign
of ulnar nerve compression at the elbow is to hold the joint in
a flexed position for 1 minute and observe for the development
of paresthesias or numbness in the ring and small fingers.
17
Less commonly, the median and radial nerves may be com-
pressed at elbow level.
19,20
The median nerve runs adjacent
to the brachial artery in the antecubital fossa and may be sensi-
tive to pressure in the antecubital space or over the proximal por-
tion of the pronator teres.
20
Gentle tapping over the course
of the median nerve may produce Tinels sign at the point of irri-
tation. Compression in the antecubital space (at the lacertus
fibrosis) is tested by actively supinating the forearm against
resistance with the elbow flexed beyond 120 degrees. For eval-
uating median nerve compression at the pronator teres, resis-
ted pronation is performed with the elbow in extension.
Compression of the median nerve may occur also as it travels
under the flexor digitorum superficialis as can be determined
with resisted flexion of the long finger.
20
For radial nerve entrap-
ment, Tinels sign along its course may likewise be elicited.
Perhaps the most important point of examining for radial nerve
entrapment is the location of the pain. Pain emanating from
radial compression is often associated with tenderness approxi-
mately 4 to 5 cm distal to the lateral epicondyle, whereas the
pain of lateral epicondylitis is present adjacent to the lateral
epicondyle.
15
Diagnostic testing
Routine diagnostic studies for elbow disorders begin with plain
radiographs. A standard elbow series consists of an AP (Fig. 5c.20),
a lateral (Fig. 5c.17), and an oblique film.
18
With a history of
trauma, it is particularly important to confirm that the radial
head is in joint as evidenced by its lining up with the capitellum
on all views. At the same time, any radial head deformity should
be noted, as well as signs of radiocapitellar degenerative changes.
A radial head view can be requested also if the radial head
cannot be adequately assessed (Fig. 5c.21). The ulnohumeral
joint can then be studied on the radiographs. In cases of degen-
erative joint disease, osteophyte formation medially or laterally
off the ulnohumeral joint is a common finding on the AP view,
and the lateral view may demonstrate osteophytes off the coro-
noid or tip of the olecranon. In cases where pathology about
the olecranon is suspected or if loose bodies are a possibility, an
axial view of the flexed elbow can be helpful (Fig. 5c.22). For
cases of suspected medial and lateral instability, stress views
demonstrate abnormal joint widening. When in doubt, compar-
ison views of the unaffected side can be obtained.
A complete interpretation of standard radiographs should
also include an assessment of soft tissue shadows for signs of
swelling or effusion. Seen with cases of elbow effusion, a radi-
olucent area posterior to the olecranon fossa represents visu-
alization of the posterior fat pad. Anteriorly, it is normal to see
a thin concave radiolucent fat pad; however, a convex fat pad
known as a sail sign indicates an elbow effusion.
CT is often helpful in the setting of trauma to identify
osseous loose bodies (Fig. 5c.23) or for cases where the osseous
anatomy is unclear on standard radiographs.
10
Offering the
benefit of soft tissue assessment, MRI is ideal for evaluating cases
of suspected cartilaginous loose bodies, assessment of tendons
when the clinical examination is unclear, assessment of collateral
ligaments, or evaluation of soft tissue masses.
10,18
It is helpful
also in cases of peripheral nerve compression by suspected soft
tissue masses such as cysts within the cubital tunnel or synovitis
extending into the radial tunnel. Proliferative synovial disorders
presenting as an isolated synovitis of unknown etiology are also
well suited to MRI evaluation.
Although less commonly used in elbow disorders, ultrasound
is useful to evaluate fluid collections around the joint and to
assess the continuity of superficial muscle tendon units such as
the triceps and biceps when the clinical examination is uncer-
tain. It has been used also to investigate for intraarticular loose
bodies
10
; however, because ultrasound requires an experienced
ultrasonographer, it is less commonly used than CT or MRI in
that setting.
Electrodiagnostics can be particularly useful in the patient
with neurologic symptoms or signs. Electromyography and
nerve conduction studies are particularly useful to determine the
presence, location, and extent of peripheral nerve compression
Chapter 5c The elbow 179
Figure 5c.20 Standard anteroposterior radiograph of the elbow.
Figure 5c.21 Radial head view.
O
T
ME
LE
O
T
LE
ME
Figure 5c.22 Axial view of elbow showing the olecranon (O), trochlea
of the distal humerus (T), medial epicondyle (ME), and lateral
epicondyle (LE).
or to identify a brachial plexus lesion or cervical radiculopathy.
Electrodiagnostic studies for cubital tunnel syndrome and poste-
rior interosseous nerve compression syndrome often demonstrate
electrophysiologic abnormalities and are helpful to confirm the
diagnosis.
15,17
In contrast, electrodiagnostic studies in cases of
radial tunnel syndrome and pronator syndrome are usually
normal.
19,20
Diagnostic blocks about the elbow are much less common
than for assessment of shoulder disorders but may on occasion
be useful. Local anesthetic injection into the radial tunnel distal
to the lateral epicondyles may help to distinguish cases of
radial tunnel syndrome from lateral epicondylitis.
15
Similarly,
a local anesthetic block may be used at a potential site of median
nerve compression at the elbow to determine whether it is respon-
sible for the patients pain.
20
Although less commonly used for elbow disorders, technetium
bone scanning may be useful to identify biologically active areas
of bone in cases of occult infection, tumor, or early degenerative
disease. When considering a diagnosis of inflammatory disease
or infection, routine blood tests such as a complete blood count,
erythrocyte sedimentation rate, C-reactive protein, rheumatoid
factor, and antinuclear antibodies may be useful. Joint aspiration
Figure 5c.23 Computed tomography showing a bony loose body in
the olecranon fossa.
should be carried out in suspected cases of infection or for
isolated effusions of unknown etiology.
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as an effective restraint to external rotation and anterior transla-
tion of the humeral head with the arm at the side of the body;
however, it is ineffective in doing so with the arm abducted to
90 degrees.
147
At 90 degrees of abduction, the subscapularis lies
above the equator of the humeral head and cannot reinforce the
anterior aspect of the shoulder.
The vascular anatomy of the cuff tendons has been reported
by many authors. Most have concluded that the supraspinatus
has a critical zone that is prone to calcium deposits and poten-
tial rupture.
103
Rathbun and MacNab
122
found that filling of the
cuff vessels was dependent on the position of the arm at the time
of injection. They documented poor filling of the supraspinatus
tendon near its attachment to the greater tuberosity and sug-
gested that tendon failure may be caused by constant pressure
from the head of the humerus which tends to wring out blood
supply to the tendon when the arm is held in the resting posi-
tion of adduction and neutral rotation.
122
The long head of the biceps may be considered a part of the
rotator cuff. It attaches to the supraglenoid tubercle of the
scapula. This structure is positioned to function as a humeral
head depressor. It also guides the humeral head as it is ele-
vated.
141
The concomitant tears that occur in the rotator cuff and
biceps tendon attest to the close functional relationship between
these two structures.
Neer stated that impingement of the rotator cuff beneath the
coracoacromial arch has been recognized as one of the causes of
chronic disability of the shoulder. Anatomically, this problem
occurs during elevation of the arm anterior to the scapular plane.
He attributed pathologic changes of the rotator cuff to mechan-
ical impingement and believed that most rotator cuff tears were
due to attritional tears from a narrow supraspinatus outlet.
24,106
Additionally, Neer discussed associated alterations on the under-
surface of the anterior third of the acromion, the coracoacromial
ligament, and in time the acromioclavicular joint. He described
three different stages of impingement. Stage I usually occurs in
patients less than 25 years old. Pathology is characterized by
edema and hemorrhage. The clinical course is reversible and con-
servative treatment is suggested. Stage II is seen in the 25-year-old
to 40-year-old age group. Pathology includes fibrosis and ten-
dinitis. These patients have activity-related pain, and treatment
may be surgical if there is no response to rehabilitation. Stage III
disease typically occurs in patients greater than 40 years old.
Pathology in this group includes acromioclavicular spurs and
full-thickness cuff tears. These patients have progressive disabil-
ity and are often candidates for acromioplasty and repair.
Bigliani et al
17
reported on a morphologic study in which the
variation in shape of the acromion was correlated with tears of the
rotator cuff. They described three types of acromion. Type I has a
flat profile, type II has a smooth curve, and type III has an angu-
lar curve or hook type of acromion. The latter type was noted to
be present in higher frequency with complete tears of the rotator
cuff. Neer
108
suggested an important role of the rotator cuff in
maintaining a so-called watertight joint space and allowing contin-
uation of the normal synovial fluid mechanics that maintain car-
tilage nutrition and may prevent secondary osteoarthritis.
The scapulothoracic joint must also be considered when rota-
tor cuff problems are managed. The scapula sits on the posterior-
lateral aspect of the thorax. It is angled approximately 30 degrees
anterior to the frontal plane. As a result of this, abduction of the
Treatment of Shoulder
Disorders
Anthony M. Buoncristiani, Paul H. Marks, and Freddie H. Fu
Disorders of the shoulder girdle are very common and can limit
participation in vocational, recreational, and professional activi-
ties. Developing an approach to the management of shoulder
disorders relies on appropriate history taking, physical examina-
tion, and imaging. This chapter outlines the treatment of most
common shoulder problems, including rotator cuff pathology;
instability; fracture and dislocations of the sternoclavicular joint,
clavicle, acromioclavicular joint, and proximal end of the humerus;
frozen shoulder; and degenerative joint disease.
ROTATOR CUFF DISEASE IN THE SHOULDER
In an older patient who complains of shoulder pain, the diagnosis
of rotator cuff disease must be considered. This entity is very com-
mon and important. In 1934, Codmans classic publication
32
sum-
marized 25 years of observations on the musculotendinous cuff
and its components. Coleman also discussed ruptures of the
supraspinatus tendon and performed the first repair of the cuff in
1909. Although there have been recent advances in diagnosis and
imaging of the rotator cuff, current views and treatments are quite
similar to concepts proposed 50 years ago.
Anatomy and function
The components or musculotendinous units of the rotator cuff are
known to function as dynamic stabilizers for the glenohumeral
joint. Electromyographic and biomechanical studies have demon-
strated the role of the rotator cuff in providing support of the cap-
sule and preventing excessive anterior and posterior movement.
Studies have suggested that the rotator cuff contributes between
one third and one half of the power of the shoulder in abduc-
tion and at least 80% of the power in external rotation.
30
The rotator cuff, which consists of the subscapularis,
supraspinatus, infraspinatus, and teres minor, functions to approx-
imate the humeral head to the glenoid cavity. The supraspinatus
assists the deltoid in abduction, whereas the subscapularis, infra-
spinatus, and teres minor serve to depress the humeral head dur-
ing elevation of the arm. Depression of the humeral head during
elevation of the arm helps to avoid impingement. The infra-
spinatus and teres minor function to externally rotate the arm.
These muscle actions may also reduce the strain on the inferior
glenohumeral ligament with the arm abducted and essentially
rotated.
28
In this position, they serve to pull the humeral head
posteriorly. The subscapularis internally rotates the arm. It serves
C HA P T E R
5d
arm relative to the scapula occurs 30 to 40 degrees anterior to the
frontal plane. Abduction of the arm in the scapular plane places
the rotator cuff muscles in their most efficient position and
reduces tension on the joint capsule.
The scapula is approximated to the thorax by the scapulotho-
racic muscles. These include the upper, middle, and lower
trapezius, serratus anterior, rhomboideus major and minor, leva-
tor scapulae, pectoralis minor, and subclavius. These muscles
must function to position and stabilize the scapula during move-
ment of the arm.
Inman et al
70
described scapulohumeral rhythm as the coor-
dinated motion between the scapula and humerus that occurs
when the arm is elevated through its full range. During the first
30 degrees of elevation of the arm, motion primarily occurs at the
glenohumeral joint and the scapula is said to be setting. Elevation
of the arm beyond this occurs in a 2:1 ratio of glenohumeral to
scapulothoracic motion. The total arc of elevation is a result of
approximately 120 degrees of motion of the glenohumeral joint
and 60 degrees of motion of the scapulothoracic joint. Motion of
the scapulothoracic joint occurs as a result of elevation and rota-
tion at the sternoclavicular and acromioclavicular joints.
Normal scapulohumeral rhythm is important for normal
function of the shoulder girdle; it allows for maintenance of the
length-tension relationship of the rotator cuff muscles, which
allows them to function efficiently throughout the full arc of
motion. Additionally, proper movement of the scapula positions
the glenoid under the humeral head to enhance glenohumeral
stability. Poor motion and positioning of the scapula have been
linked to impingement and rotator cuff problems.
Classification of injury
Cuff tendon failure can be classified by various criteria. These
include partial- or full-thickness tears, acute or chronic injury,
and traumatic or degenerative etiology. The cuff pathology is
almost always near the tendon insertion. It nearly always occurs
in the supraspinatus component of the rotator cuff, because this
is the area that is subject to mechanical impingement against the
coracoacromial arch. A full-thickness tear extends from the bur-
sal side through to the humeral aspect of the cuff. A partial tear
may involve the bursal or the humeral side of the tendon. Acute
tears occur suddenly and are found in only a relatively small por-
tion of patients with rotator cuff pathology. Chronic tears are more
common and are usually insidious in onset. It should be noted that
the size of the complete tear can also be used to describe the
pathology. A massive tear is the term used by Cofield
33
to
describe a defect more than 5 cm in diameter.
The incidence of full-thickness rotator cuff tears has been
documented in various cadaver studies as being between 5% and
26.5%.
111,157
The incidence of cuff pathology has also been
documented in clinical subjects. Age has been found to correlate
with incidence.
102
Moseley
102
found that the incidence rose dra-
matically with the age of the patient. Traumatic cuff tears have
also been found in patients with anterior-inferior dislocations.
Arthrographically documented tears were seen in 30% in the
fourth decade and 60% in the sixth decade.
119
The role of secondary impingement and eccentric overload
has been recognized in the pathogenesis of rotator cuff injuries in
throwing athletes.
71
It is hypothesized that in throwing athletes,
weakness and fatigue of the rotator cuff results in overload of the
passive restraints. This results in laxity and subluxation of the
glenohumeral joint and leads to secondary impingement.
Additionally, the rotator cuff muscles are eccentrically overloaded
as they attempt to stabilize the head of the humerus in the gle-
noid cavity. Repetitive eccentric overloading of the rotator cuff
results in inflammation and injury to the rotator cuff tendons.
Clinical presentation
History
Most patients with rotator cuff pathology are over 40 years of age.
Fifty percent of patients recall a traumatic incident that initiated
the symptoms. They usually do not describe a major injury. One
can usually elicit a history of recurrent bursitis and/or ten-
donitis; these episodes often resolve with rest or other conserva-
tive measures. With time, there is increasing shoulder discomfort.
This is noted with forward elevation and external rotation of the
arm against resistance. Patients may have complaints of nocturnal
discomfort, particularly when sleeping on the affected side.
Patients may describe crepitation with movement.
The physical findings may be related to the underlying pathol-
ogy. Crepitation would relate to the lack of smooth surfaces in
the subacromial space. Weakness of flexion, abduction, and
external rotation relates to loss of the tendonous attachment to
bone. Upward riding of the humeral head on deltoid contraction
results from a loss of the depressor action of the rotator cuff, and
this further exacerbates impingement and cuff degeneration.
Partial tears of the rotator cuff may cause pain with motion,
crepitation, and stiffness. A complete tear may reveal a palpable
defect of the cuff. As previously noted, associated tendonitis of
the biceps may be present, and this should be documented.
The patient should be examined for impingement signs.
Specifically, this includes full-forward flexion with pain at termi-
nal motion, otherwise known as the Neer impingement sign.
Pain may also be elicited with the Hawkins test, a provocative
test that elicits pain from impingement by bringing the arm into
forward flexion, adduction, and internal rotation, thus driving
the supraspinatus insertion into the coracoacromial arch and cre-
ating pain. The acromioclavicular joint can be stressed with
cross-chest adduction. Stability of the biceps tendon should be
elicited. Bicipital pathology tests include those of Speed and
Yergason. Speeds test reproduces pain with resisted forward ele-
vation of the humerus against an extended elbow. The pain is
localized to the bicipital groove area. Yergasons test reproduces
pain over the bicipital groove with resisted supination of the
forearm with a flexed elbow. Muscle strength testing about the
shoulder is part of the neurologic examination and should be
documented.
Differential diagnosis
When assessing a patient with a suspected tear of the rotator
cuff, one should consider other underlying pathologies in the
differential diagnosis. These include cuff tendonitis, bursitis,
frozen shoulder, cervical spondylosis, suprascapular neuropathy,
Chapter 5d Treatment of shoulder disorders 182
snapping scapula, acromioclavicular or glenohumeral arthritis,
and glenohumeral instability.
Methods of treatment
Despite rotator cuff pathology, not all patients are symptomatic,
so aggressive treatment is not indicated in an asymptomatic
shoulder. In a symptomatic shoulder, the goals of treatment are
elimination of pain, restoration of function, and prevention of
recurrence or progression.
Nonoperative treatment
Nonoperative modalities of treatment include physical therapy,
rest, elimination of aggravating activities, and administration of
antiinflammatory medications and steroid injections. In one
study, 44% of the patients with arthrogram-proven rotator cuff
tears were shown to respond to nonoperative treatment.
143
Successful nonoperative management of impingement and
rotator cuff injuries requires an understanding of the anatomy
and biomechanics of the shoulder girdle and an appreciation of
the underlying etiology. Treatment is based on the patients signs
and symptoms at examination. Progression should be based on the
response to treatment. General goals for the rehabilitation of an
individual with rotator cuff pathology are listed in the box on
this page.
Patients with acute signs and symptoms complain of constant
pain at rest that is referred distally over the deltoid insertion, and
they generally exhibit decreased motion with pain before resist-
ance with passive testing.
During this phase, the focus of treatment is on pain control.
This includes the use of relative rest to avoid those activities that
aggravate the symptoms. Additionally, the patient is encouraged to
position the arm in abduction in the scapular plane. This reduces
pain and prevents wringing out of the rotator cuff as described
earlier. Pain-relieving modalities are used and may include ice,
moist heat, and transcutaneous electrical nerve stimulation. Gentle
mobilization and range-of-motion exercises are performed to
prevent loss of motion and development of a stiff shoulder.
Patients in the subacute phase have intermittent pain that is
more localized to the shoulder. The pain may be aggravated by
repeated movements. Motion may be limited and resisted testing
may be weak and painful. During this period, treatment contin-
ues to consist of relative rest, and modalities can be used to
decrease pain and promote healing. The intensity of exercise can
be progressed. The focus is on restoration of the normal motion
necessary for function of the individual. Full range of motion
must be restored, with particular emphasis on restoration of
external rotation. External rotation is necessary so that the
greater tuberosity can clear the acromion as the arm is elevated
overhead. Joint mobilization techniques should be used if gleno-
humeral mobility is decreased. Often, the posterior capsule is
tight and requires stretching. Stretching exercises can also be
used to increase motion. Joint mobilization should be avoided
for patients with hypermobility. For these patients, the focus of
treatment should be on the development of dynamic stabiliza-
tion. This requires strengthening of the rotator cuff and proprio-
ceptive exercises to retrain the muscles to dynamically stabilize
the glenohumeral joint. Finally, strengthening of the axioscapu-
lar muscles (serratus anterior, trapezius) is important to establish
normal scapulothoracic motion and decrease the role of scapu-
lothoracic dyskinesia in impingement biomechanics.
Strengthening exercises begin with isometrics with the shoul-
der positioned in 30 to 45 degrees of abduction in the scapular
plane. Active and light progressive resisted exercises are initiated
as tolerated. These should specifically strengthen the rotator cuff
muscles. Several studies have demonstrated maximum elec-
tromyographic activity in the rotator cuff muscles with a variety
of exercises.
18,146
The supraspinatus may be strengthened by per-
forming abduction in the scapular plane with the arm internally
rotated, but caution must be taken to avoid further impingement
with this exercise. Additionally, the supraspinatus may be
strengthened by performing prone horizontal abduction with
the arm abducted to 100 degrees in the frontal plane and maxi-
mally externally rotated. The infraspinatus may be strengthened
by performing prone horizontal abduction with the arm abducted
to 90 degrees in the frontal plane and externally rotated. The teres
minor may be strengthened by prone external rotation with the
arm abducted to 90 degrees. The subscapularis may be strength-
ened by performing internal rotation with the arm at the side.
Both eccentric and concentric phases of the rotator cuff exercises
are emphasized. Adding excessive resistance to these exercises
should be avoided because it will only result in substitution by
larger muscles of the shoulder complex. These exercises must be
performed precisely without substitution to develop specific mus-
cles of the rotator. Internal and external rotation with the arm at
the side of the body will not fully develop the rotator cuff.
Strengthening exercises for the scapular muscles should also be
included. Particular emphasis should be placed on strengthening
the middle and lower trapezius as well as the serratus anterior.
Successful treatment of rotator cuff injuries is dependent on
an understanding of the underlying anatomy and biomechanics,
as well as an appreciation of the underlying etiology. Treatment
must be appropriate for the patients stage of inflammation.
Knowledge of the functional demands placed on the shoulder
is also necessary. Signs of overly aggressive treatment must be
recognized and include increased pain greater than 2 hours after
treatment and/or regression of motion or strength. If the
patients symptoms do not improve after 3 to 6 months, further
investigation with imaging modalities as discussed before is indi-
cated. Some would suggest that nonoperative treatment should
continue, but only about 50% of such patients respond.
Operative treatment
Samilson and Binder
135
outlined the following indications for
operative repair: (1) a patient physiologically younger than
Chapter 5d Rotator cuff disease in the shoulder 183
Goals of rotator cuff treatment
Control pain
Restore motion
Improve rotator cuff function
Strengthen scapular muscles
Correct posture
Resume function
Prevent recurrence
60 years, (2) a clinically or arthrographically demonstrable full-
thickness cuff tear, (3) failure of the patient to improve with
nonoperative management for a period not less than 6 weeks,
(4) a need to use the involved shoulder in overhead activities in
the patients vocation or avocation, (5) full passive range of
motion, (6) a patients willingness to exchange decreased pain and
increased external rotator strength for some loss of active abduc-
tion, and (7) the ability and willingness of the patient to cooperate.
Currently, anterior acromioplasty with limited detachment
of the deltoid appears to be the most direct, least harmful, and
most effective procedure for persistent rotator cuff tendonitis.
Ellman
43
documented an 88% satisfactory result rate in patients
who have chronic impingement treated by arthroscopic
acromioplasty. Simple debridement of partially torn rotator
cuffs has allowed an 85% rate of return to activity in a group of
patients treated by Andrews et al.
7
Although acromioplasties are
still routinely performed in conjunction with rotator cuff
repairs, recently Matsen and coworkers
91
published their results
on 96 patients who underwent mini-open rotator cuff repair with-
out acromioplasty. Significant improvement in self-assessed shoul-
der comfort and in each of the 12 shoulder functions was observed.
Burkhart
26
published results of arthroscopic treatment of mas-
sive rotator cuff tears. He treated 10 patients with painful, mas-
sive, complete tears involving primarily the supraspinatus with
arthroscopic acromioplasty and rotator cuff debridement. All
patients except one had normal preoperative motion and strength.
These patients maintained adequate mechanics of the gleno-
humeral joint during abduction because there is a balance of two
important force couples.
120
The first force couple is in the coronal
plane and consists of the rotator cuff and deltoid such that the
rotator cuff maintains a fixed fulcrum for rotation of the deltoid
during abduction. The second force couple acts in the transverse
plane and consists of a balance between the anterior and posterior
portions of the rotator cuff that allows the humeral head to main-
tain centering during rotation of the glenohumeral joint. This
study showed that normal shoulder function is possible with mas-
sive unrepaired rotator cuff pathology. Similar results were seen
with Motycka et al
104
with their cohort of 64 patients with large
rotator cuffs tears followed for a mean period of 5 years.
As arthroscopic techniques improve, more surgeons are treat-
ing rotator cuff pathology arthroscopically. Several articles have
been published demonstrating equal results comparing all arthro-
scopic versus mini-open rotator cuff repair.
25,137,148
However, for
most cuff tears that come to operative management, an open
approach is still used. The extent of the rotator cuff tear is ascer-
tained at the time of surgery, and the torn edges of the rotator
cuff are identified. The following sequence has been suggested for
closure: (1) resection of the bursal scar, (2) identification of the
tear, (3) assessment of tissue mobility, (4) mobilization of the
rotator cuff, and (5) planning for closure, either side to side or in
most cases to a trough in bone.
81
Concomitant acromioplasty is
performed in these patients. Long-term results of this technique
were reported by Bigliani et al.
16
In patients with an average fol-
low-up of 7 years, 85% had satisfactory results with adequate pain
relief and 92% could raise the arm above the horizontal plane.
Many techniques have been described for massive tears that
cannot be treated as just outlined. These options include accepting
the defect, moving local tissue into the deficient area, and inserting
a free graft of local or distant tissue, that is, either an allograft,
xenograft, or prosthetic material.
34
Latissimus dorsi transfer for
the treatment of massive tears of the rotator cuff has been
described by Gerber et al.
53,55
In cases with good subscapularis
function but irreparable defects in the external rotator tendons,
restoration of approximately 80% of normal shoulder function
was obtained. In fact, in a cohort of patients with massive rota-
tor cuff tears, Harryman et al
59
reported patient satisfaction
regarding comfort and function despite greater than 50%
demonstrating recurrent tears determined by ultrasonography.
Postoperative care
Postoperative care after surgery on the rotator cuff is dependent
on the status of the deltoid, the size of the repair (i.e., small ver-
sus massive), the ability to mobilize tissue, and the safe range of
motion achieved at surgery. Therefore, postoperative care must
be individualized to the patient and the procedure rather than
everyone being treated with a standardized protocol.
Immediate postoperative care after rotator cuff surgery should
protect the healing structures, control pain, and restore range of
motion. For small tears, the arm is generally immobilized at the
side for 4 to 6 weeks with a deltoid-splitting technique. Pain-
relieving modalities can be used to improve comfort. Passive
range-of-motion exercises are begun immediately postoperatively
and performed several times per day in the range prescribed by
the surgeon. Once sufficient healing has occurred (i.e., at 4 to
6 weeks), active assisted and active range-of-motion exercises can
be initiated. Strengthening exercises using isometrics can also be
initiated at this time.
Postoperative management after the repair of massive tears in
which the deltoid was detached includes immobilization for up
to 6 weeks. Generally, an abduction pillow is used to reduce ten-
sion on the postoperative repair. Modalities are used to control
pain as necessary. Passive range of motion is performed for the
first 6 weeks. The safe range of motion achieved at surgery must
be communicated by the physician to the therapist. Active
assisted and active range-of-motion exercises are delayed for
6 weeks to ensure adequate tissue healing. Isometric strengthen-
ing exercises are usually delayed until 12 weeks after surgery.
Once sufficient time for healing has passed, the patient is
gradually progressed through the rehabilitation program. Initial
emphasis is on restoring the motion necessary for normal func-
tion of the shoulder complex. Attention is directed at reestablish-
ing normal scapulohumeral rhythm. Additionally, strengthening
exercises focus on developing the rotator cuff and scapular mus-
cles. Functional activities are incorporated to allow gradual
resumption of function. The patient must be willing to accept
some limitation in level of function.
In patients who complain of shoulder pain, pathology of
the rotator cuff is important to consider because of the large
spectrum of disease from impingement to complete and massive
tears of the rotator cuff. Many patients may respond to nonop-
erative therapy, although slightly fewer than 50% may fall into
this group. After careful history taking and physical examination,
most patients can initiate a course of nonoperative management.
In those patients who do not respond, imaging of the cuff is the
next appropriate step in the algorithm. In patients with simple ten-
dinitis or impingement, conservative management is continued.
If symptoms persist, acromioplasty, either open or with endoscopic
techniques, can be considered. Patients with complete disruption
or full-thickness disruption may be candidates for other operative
approaches as outlined earlier. The most direct and simple repair
technique is often the most appropriate: progression from direct
tendon repair, to repair of bone, to transposition of local tissue, to
grafting. Postoperative support should vary according to need.
Physiotherapy after surgery is a vital part of the treatment protocol.
SHOULDER INSTABILITY
A rational approach to surgical management of instability should
be based on an understanding of the definition of successful repair
and an appreciation of the reasons for failure. Successful surgery is
traditionally defined as elimination of recurrence of instability.
According to this definition, up to a 97% rate of excellent results
has been reported with a large variety of procedures.*
Both operative and nonoperative treatment must be based on
an appreciation of the spectrum of glenohumeral instability.
A classification system for shoulder instability should include
the following factors: frequency of occurrence, etiology, direction
of instability, and degree of instability. One can distinguish
between traumatic recurrent instability and atraumatic recurrent
instability. The former occurs as a result of a single episode of
macrotrauma, is usually unilateral, is less responsive to a rehabil-
itation program, and has the Bankart lesion as the most common
primary pathology. The latter may occur as the result of repeti-
tive microtrauma (e.g., swimming or throwing), may be bilateral,
is responsive to a therapy program, and has excessive capsular
laxity as the most common primary lesion. Voluntary instability is
found in a subset of individuals with a traumatic instability. These
patients can be further subdivided into two groups. Group I
patients with voluntary instability have an arm position-depend-
ent instability that is usually posterior but may be anterior. These
patients usually respond to rehabilitation and do not have an
underlying psychiatric disturbance. If they remain refractory to
conservative treatment, they may be well managed by surgery.
Group II patients have the ability to selectively contract muscles
to create a dislocation. Some of these individuals have an under-
lying psychiatric disturbance and use their instability as a trick to
control their environment.
131
These individuals are not candi-
dates for surgical treatment and are better managed by psychi-
atric counseling and conservative rehabilitation.
There is a spectrum of glenohumeral instability in which
subluxation and dislocation represent degrees of injury to the cap-
sulolabral structures. Dislocation is defined as complete separation
of the articular surfaces, and subluxation represents increased
humeral head translation within the glenoid to a degree beyond
normal tissue laxity. Because the parameters of normal gleno-
humeral translation have not yet been fully defined,
136
clinical sub-
luxation is defined as detectable glenohumeral translation with
accompanying symptoms. The increased use of arthroscopy has
led to the characterization of an additional group within this spec-
trum of instability. This group appears to be throwing athletes in
whom symptomatic labral tears or attrition develops secondary to
increased glenohumeral translation without clinical subluxation.
4,6,9
Appreciation of the direction of instability is critical to selec-
tion of a successful approach to treatment. Traditionally, 95% of
all instability has been observed to be simple anterior instability;
however, there has been increasing recognition of significant
posterior instability in athletes who are loose-jointed individu-
als.
8,52
Posterior instability is usually subluxation inasmuch as dis-
location occurs only with rarer traumatic episodes.
52
Since Neer
and Fosters article on multidirectional instability (MDI), there
has been an increasing awareness of both atraumatic and trau-
matic capsular laxity occurring in more than one direction. The
main direction of instability is usually anterior, although inferior
instability appears to be the hallmark of this diagnosis.
5,37,49,109,112
Traditional procedures that treat anterior capsular laxity by
Bankart repair or capsular plication do not adequately manage
the associated components of inferior and/or posterior instability.
In the worst scenario, these procedures can actually lead to insta-
bility in the opposite direction.
Failure of the operative approach may occur at any point in
the course of treatment and may be due to either physician or
patient error or a combination of the two. For a successful out-
come, the diagnosis, surgical procedure, and rehabilitation must
be individualized and appropriate in each case.
A correct diagnosis is critical in categorizing the instability and
recommending the appropriate form of treatment. For example,
a misdiagnosis of impingement or failure to recognize a con-
comitant rotator cuff tear in a patient over the age of 50 may
lead to failure despite a technically adequate anterior stabiliza-
tion procedure. Additionally, a Bankart procedure that ignores
the inferior component of capsular laxity in a patient with MDI
will fail.
Assuming a correct diagnosis, a variety of technical pitfalls is
encountered with each type of stabilization procedure. Appropriate
anterior capsular tension must be restored, and procedures that
over-tighten the anterior capsule or subscapularis tendon may
result in serious functional limitation of external rotation. In some
cases this may lead to osteoarthritis or exacerbation of posterior
instability in patients with unrecognized MDI.
63,159
Knowledge of the regional anatomy or an inadequate exposure
predisposes to an inadequate repair and possible neurovascular
injury.
125
Assuming the correct diagnosis and correct procedure,
the failure of patient compliance or inappropriate rehabilitation
may result in limited range of motion or recurrence of instability.
To avoid complications of treatment, it is critical to be both
sensitive and specific in the initial diagnostic assessment of the
individuals shoulder complaints. Both the degree and direction
of any instability must be accurately determined, and any associ-
ated fractures, neurovascular injury, or concomitant rotator cuff
pathology must be identified.
Impingement syndrome
Impingement syndrome may occur either as an isolated entity or
in combination with instability.
62,156
Hawkins and Hawkins
63
identified several patients whose untreated impingement syndrome
was the cause of their ongoing pain after anterior shoulder stabi-
lization. This should not be confused with the common finding
in patients with anterior instability of pain located posteriorly in
combination with clinical findings consistent with impingement
Chapter 5d Shoulder instability 185
*References 1, 2, 6, 14, 21, 22, 29, 41, 47, 72, 84-88, 90, 97, 101, 109, 112, 124, 130,
139,144.
syndrome.
64,150
This impingement pain is likely a secondary phe-
nomenon related to repetitive traction and compression of the
rotator cuff during subluxation or to overwork of the rotator cuff
muscles in an attempt to maintain the humeral head centered in
the glenoid in the setting of capsular insufficiency. Jobe et al
72,134
described this overlap in the literature, and Altchek et al
6
observed
a 20% incidence of impingement symptoms in individuals with
surgically confirmed anterior-inferior MDI. In most cases it is pos-
sible to correctly diagnose impingement syndrome from the his-
tory and examination; however, if this evaluation is inconclusive,
examination under anesthesia and arthroscopic inspection assist in
clarification of the diagnosis.
Anterior shoulder instability in a patient older than 40 years
of age is a unique situation that deserves special consideration if
complications and failure of treatment are to be avoided. The
association of concomitant anterior shoulder dislocation and
rotator cuff tear has been reported by numerous orthopedic sur-
geons.
This concomitant injury may be missed if one is not

attentive. Moreover, there is an increased risk for adhesive cap-
sulitis in this older group of patients if early range of motion is
not begun after reduction of a dislocation.
The incidence of an associated rotator cuff tear in this group
has been reported to be as high as 70% to 90%.
62,94,95
Most
recently, Neviaser et al
113
and Hawkins et al
62
increased our under-
standing of this problem. Anterior dislocation in an older individ-
ual may result in disruption of a rotator cuff that has undergone
age-related attrition. The anterior capsulolabral structures are
spared.
62,123
McLaughlin
92
and subsequently Craig
38
termed this
the posterior mechanism of anterior shoulder instability.
In older patients with persistent external rotation and abduc-
tion weakness after the reduction of an anterior dislocation,
physicians should avoid the trap of assuming an axillary nerve
injury as the etiology.
38,113
The overall incidence of clinically sig-
nificant axillary nerve injury in this setting has been reported to
be in the range of 9% to 18%.
19,126
Neviaser et al
113
observed an
incidence of 7.8% for axillary nerve injury in association with
rotator cuff tear after anterior dislocation. A suprascapular nerve
injury is rare in the setting of anterior dislocation.
38
In general, older patients have a lower rate of recurrence of
instability after an initial episode of anterior instability.
132
This is
particularly true if there is an associated fracture of the greater
tuberosity that reduces the range of motion of the joint and mus-
cle strength.
95,126
In older patients with an unrecognized rotator
cuff tear, pain and weakness appear to be more common prob-
lems than recurrent instability.
62,113
In a separate group of older patients, recurrent anterior shoul-
der instability develops as the result of an excessively redundant
anterior capsule and no rotator cuff tear.
77
These individuals typ-
ically demonstrate the stigmata of generalized ligamentous lax-
ity, including thumb to forearm; hyperextension of the elbow,
knee, and metacarpal joints; a history of easy bruising, hernias,
and scar spreading; and excessive skin laxity. These features
should be documented during the examination.
An approach to treating older individuals (>45 years) after an
initial shoulder dislocation is based on classifying such patients
into three groups:
Group I: If after reduction no significant weakness of external
rotation or abduction is found, immobilization should be
continued no longer than 7 to 10 days. A gentle range-of-
motion program should begin and progressive supervised
therapy should follow. Failure to move the shoulder early in
these patients can result in marked limitation of motion.
Group II: Patients with persistent pain and external rotation and
abduction weakness likely have an associated rotator cuff tear.
Early arthrography and electromyography should be performed
to confirm this fact and to rule out any associated axillary nerve
injury. Conservative treatment in this setting usually results in a
poor outcome.
63
Early repair of the rotator cuff generally yields
good results, and surgery performed after a delay in diagnosis
may be fraught with difficulty because the cuff tissues may
become extensively scarred and difficult to mobilize.
62,113
If the
patient does have an associated axillary nerve injury, we would
still perform an early repair of the cuff, although final function
will likely be determined by return of axillary nerve function.
Group III: Recurrent instability in older patients may be due to
either a rotator cuff tear or excessive capsular laxity.
62,77,113
Labral lesions may occur but are less common in this group.
Examination usually reveals those patients with generalized
ligamentous laxity, but an arthrogram is essential to clarify
the status of the rotator cuff. It is prudent to know the pathol-
ogy before surgery is attempted because most cuff pathology
is best treated through an anterior superior approach with an
acromioplasty, whereas anterior capsulolabral pathology is
managed through a deltopectoral interval approach. It should
be noted that Neviaser et al
113
observed a significant sub-
scapularis tear in all cases of recurrent instability.
Fracture of the greater tuberosity, the second most common
associated fracture after the Hill-Sachs lesion, occurs in about
10% of all anterior dislocations.
92
In most cases this fracture
reduces anatomically with reduction of the glenohumeral joint
and recurrence of shoulder instability is actually less than if no
fracture were present.
92
Displacement of the greater tuberosity
fragment more than 1 cm may result in residual impingement
and blocked external rotation. In these cases, surgical reduction
and fixation may be necessary.
A glenoid rim fracture may occur with anterior dislocation
and continued displacement of the anterior glenoid articular sur-
face of greater than 25% to 35% results in recurrent instabil-
ity.
11,80,129
Computed tomography demonstrates this clearly, and
surgical reduction and fixation may be necessary if residual
displacement is greater than 2 mm.
The axillary nerve is the most commonly injured neurovascular
structure, with the reported incidence ranging from 5% to 33% in
first-time dislocators.
19,130
Both a motor and sensory examination
should be performed before and after any reduction maneuver
because complete motor paralysis may occur without any detectable
hypoesthesia. Any residual neurologic deficit persisting longer than
3 to 4 weeks should be evaluated by electromyography.
19
Most
patients spontaneously recover over a 6-week period inasmuch as
most of these injuries are neuropraxic in nature.
The axillary artery is occasionally damaged with anterior
dislocation because it is relatively fixed as it passes beneath the
pectoralis minor and over the subscapularis.
39,73,92,126
This is par-
ticularly the case in older individuals, in whom atherosclerosis
References 32, 65, 93-95, 113, 142.

may render the vessels less compliant to displacement. Clinical
findings include severe pain, expanding hematoma, and dimin-
ished peripheral pulses; an arteriogram should be performed
urgently in such cases because timely repair is crucial to a suc-
cessful outcome.
Failure to recognize the voluntary aspect of a patients insta-
bility may result in the failure of any procedure for recurrent
instability. Rowe et al
131
described a typical patient in this group as
an adolescent with an underlying psychiatric problem, without any
prior history of significant trauma, who can voluntarily dislocate
his shoulder and who has essentially normal radiographic findings.
As already noted, group I patients are typically emotionally stable
individuals with positional instability.
52
Group I patients repre-
sent a subset of atraumatic voluntary instability, and if they fail to
respond to conservative management, an operative procedure that
reduces the excessive capsular laxity is a reasonable alternative. It
is crucial to sort out this group from those in group II, who have
a muscular-control type of voluntary instability that may be used
as a trick to control the environment. These individuals are man-
aged by psychiatric counseling and rotator cuff strengthening
exercises. The spectrum of MDI includes those individuals with
excessive ligamentous laxity (atraumatic type), those with instabil-
ity resulting from repetitive overhead activities with extremes
of motion (microtrauma type), and those with instability after
violent trauma (macrotrauma type).
6,140
Recognition of MDI is critical because traditional stabilization
procedures such as the Bankart or Bristow operations fail to ade-
quately address the inferior component of instability.
Moreover,
too tight an anterior repair in this setting may actually aggravate
the posterior component of MDI.
64,159
The diagnosis of MDI is based on the history and the classic
finding of a significant sulcus sign in addition to anterior-
posterior laxity demonstrated with a load-and-shift maneuver.
Furthermore, 50% of these individuals usually have stigmata of
generalized ligamentous laxity.
Up to 50% to 70% of these individuals respond well to a
rehabilitation program aimed at rotator cuff strengthening if it is
coordinated with activity modification. This is in contrast to
young individuals with posttraumatic, unidirectional, anterior
recurrent instability, who often require surgery.
27
Missed unreduced anterior dislocation may occur in elderly
patients, individuals with substance abuse, individuals with seizure
disorders, and unconscious polytraumatic patients.
60,133
Unlike
missed posterior dislocations that go unrecognized because of a
failure to perform an adequate radiograph, missed anterior dislo-
cations are usually due to a failure to perform an initial or fol-
low-up radiograph.
60
The chronicity of the dislocation must be
established. If an anterior dislocation is less than 6 weeks old and
no concomitant osteoporosis or history of steroid use is present,
an attempt at mild gentle closed reduction may be made under
general anesthesia.
60
In cases with chronic unreduced disloca-
tions older than 6 weeks, open reduction and stabilization are
recommended. In these cases, an axillary radiograph confirms
the diagnosis; however, computed tomography gives valuable
information about the status of the humeral head and glenoid.
It is helpful to have this information before surgery because
significant bone loss of the anterior glenoid or posterolateral
humeral head may necessitate supplemental bone grafting. In
older individuals, an arthrogram may also be appropriate to rule
out an associated cuff injury.
An anterior surgical approach through the deltopectoral inter-
val is recommended. If necessary for exposure, the superior 1 cm
of the pectoralis major insertion may be detached. The anterior
1 cm of the conjoined tendon insertion at the level of the cora-
coid process can be divided. The subscapularis is usually con-
tracted and fibrotic along with the capsule and rotator cuff, and
the axillary nerve may be stretched tightly across the anterior
glenohumeral joint. This must be kept in mind during release of
these tight anterior structures. After release of the subscapularis
and capsule, it is often necessary to remove granulation tissue
within the joint before the humeral head is reduced. After reduc-
tion and repair of the capsule, early motion is preferred rather than
spica immobilization advocated by some surgeons.
60
Management
of glenoid bone deficiency and large Hill-Sachs lesions is dis-
cussed later.
In cases in which the dislocation is older than 1 year or when
the Hill-Sachs lesion is larger than 50% of the articular surface,
the humeral head may no longer be viable and a hemiarthro-
plasty may be the best alternative treatment. In these cases,
placement of the prosthesis at an angle greater than the normal
retroversion of 30 degrees (50 to 60 degrees) helps prevent the
recurrence of anterior instability.
Although most procedures have a success rate in excess of
95% in providing stability to the shoulder, no single surgical
technique is perfect. In general, procedures that do not address
specific pathology should not be used in the primary surgery set-
ting. An individualized approach to each situation is recom-
mended, because a variety of pathologic lesions may be present
in different patients.
The optimum technique, as defined by Cofield et al,
35
would
be one with the following characteristics: low recurrence rate, low
complication rate, low reoperation rate, low rate of osteoarthritis
(uses no hardware), no limitation of motion, anatomic treatment
of pathology, and no technical difficulty. Because no one proce-
dure satisfies all these criteria, we present specific pitfalls and
their management for a variety of common anterior stabilization
techniques.
Examination under anesthesia
and diagnostic arthroscopy
It is essential to confirm both the direction and the degree of
instability by examination under anesthesia before any surgical
procedure. This aids in the decision of which operative approach
and procedure to use. One should perform a drawer test on the
shoulder to assess the amount of anterior, posterior, and inferior
translation of the humeral head in the glenoid. Anterior and pos-
terior translation is assessed with the shoulder at 90 degrees abduc-
tion and neutral rotation and is graded on a scale of +1 to +3
(+1 is movement of the humeral head to the rim but not over it,
+2 represents humeral head dislocation over the glenoid rim
with spontaneous reduction when pressure is released, and +3
is frank dislocation of the humeral head that does not reduce
spontaneously).
6
One should not be surprised to find increased
Chapter 5d Shoulder instability 187
References 6, 49, 54, 90, 109, 112, 121, 126, 127, 140.
posterior translation along with anterior translation when a
patient with suspected anterior instability is examined because
injury to the ligaments on both sides of the joint may occur with
an anterior dislocation.
115,136
Inferior instability is assessed by the presence of a sulcus
sign. This test is performed with downward traction on the
adducted arm, and the degree of acromiohumeral interval separa-
tion is noted.
150
The sulcus sign is graded on a scale of +1 to +3
(+1 is 0 to 1 cm, +2 is 1 to 2 cm, +3 is greater than 2 cm).
6
Arthroscopic inspection may occasionally be useful in these
patients, although office examination, history, and an examina-
tion under anesthesia usually confirm the diagnosis. Most labral
lesions below the equator of the glenoid are associated with a
deficient inferior glenohumeral labrum.
Surgical procedures for instability
The classic Bankart procedure
13,118
and its modifications
72,130,144
anatomically repair a detached glenoid labrum together with the
inferior and middle glenohumeral ligaments. Several variations
in handling of the subscapularis deserve mention. Thomas and
Matsen
144
described a technique first proposed by Ellison. The
subscapularis and capsule are both divided laterally, with medial
retraction allowing repair of the Bankart lesion with the joint in
an inside-out fashion. This approach is useful in revision cases in
which extensive scarring is found medially at the glenoid.
Jobe and Glousman
72
recommended longitudinal division of
the subscapularis muscle with preservation of its lateral insertion
on the lesser tuberosity. This approach is designed to minimize
scarring and shortening of the muscle in a throwing athlete.
Several potential problems with this approach include limited
inferior exposure in cases in which a capsular shift might be
necessary and the potential for injury to the axillary nerve
and brachial plexus if longitudinal splitting is carried too far
medially.
To repair the Bankart lesion once the sutures are well placed
through the bony anterior glenoid rim, the lateral capsule is
repaired to the rim. A potential error here is to not address any
concomitant capsular laxity. The standard Bankart procedure
handles capsular laxity by placing the sutures more laterally
through the lateral capsular flap. The T-plasty repair pulls the
inferior portion of the capsule superiorly before placement of
the sutures through the capsule.
The inferior capsular shift procedure as originally described by
Neer and Foster
112
is designed to treat excessive capsular laxity
occurring with MDI. It has been used successfully and involves
detachment of the capsule laterally along its humeral attachment
with a superior-lateral shift of the inferior flap and then an infe-
rior-lateral shift of the superior flap.
40,49
Repair of an associated
Bankart lesion is performed first, and failure to address this lesion
has been associated with failure of the procedure.
87
Inferior
detachment of the capsule laterally along the humeral neck prob-
ably involves less risk to the axillary nerve than does a medial
paraglenoid capsulotomy incision; however, there is still signifi-
cant risk with inferior dissection, and Neer
109
observed three cases
of axillary nerve neuropraxia early in his experience. To avoid this
potential complication, the inferior flap should be developed by
placing stay sutures in the capsule and pulling superiorly while
applying progressive external rotation. An elevator is placed infe-
riorly and used to remove any muscle from the capsule before its
division. If the axillary nerve cannot be palpated and its exact
location is not precisely known, it should be visualized before
division of the inferior capsule.
A T-plasty procedure can be performed to manage capsular
laxity and concomitant labral detachment simultaneously.
6
The
basic goal of the T-plasty is to restore proper tension in the infe-
rior glenohumeral ligament by advancing this structure superi-
orly and medially. At completion of the capsular repair, external
rotation with the arm at the side should be in the range of 35 to
45 degrees without undue tension on the repair.
The Bristow procedure and its modifications basically involve
fixation of the coracoid process and attached conjoined tendon
to the scapular neck through a split in the subscapularis tendon.
The procedure theoretically functions by provision of an ante-

rior bone block, formation of a dynamic musculotendinous
sling, and partial tenodesis of the inferior third of the subscapu-
laris tendon. It does not directly address pathologic lesions such
as labral detachment or capsular laxity.
Although the Bristow procedure has a success rate compara-
ble with that of other procedures, it is generally accepted to be a
poor alternative for stabilization in athletes involved in overhead
sports, because it may limit external rotation.
14,66,85,86
The ortho-
pedic literature has documented a high incidence of complica-
tions with this procedure.
10,12,46,159
The major risk with the Bristow procedure is injury to the
musculocutaneous nerve.
12,15,48,125,159
This complication is usually
due to inadequate knowledge of variations in regional anatomy or
poor surgical technique.
125
Significant variations in anatomy of
the conjoined tendon and musculocutaneous nerve may be
encountered.
48,125
The musculocutaneous nerve, in most cases,
enters the coracobrachialis muscle at a distance of 5 or more cm
distal to the coracoid process; however, in 5% of cases it may
also be as close as 2.5 cm from the tip of the coracoid.
12,48,125
If the nerve is observed to enter the muscle at 2.5 cm or closer
to the coracoid process, the Bristow procedure should not be
performed. Finally, staple fixation may impinge or rupture the
biceps tendon with improper placement.
The Putti-Platt procedure treats anterior instability by shorten-
ing the subscapularis in a vest-over-pants technique to limit
external rotation.
22,68,84,116
The subscapularis is detached 2.5 mm
medial to its insertion, and the capsule and subscapularis are then
sutured to the glenoid rim with the arm in internal rotation. The
main complication of this procedure is loss of function from
excessive limitation of external rotation, and in the extreme case
this may result in secondary glenohumeral arthritis caused by
excessive constraining forces on the articular surfaces.
61
Instability
may also result if the patient has unrecognized MDI.
63
In the duToit capsulorrhaphy procedure, a staple is used to
effect a Bankart-type repair, and complications stem from prob-
lems with staple fixation and placement.
20,42,139
Injury to the
articular surface and loosening of the staple have been
reported.
160
Metal devices are mentioned here for their historical
role in the development of arthroscopic Bankart repairs.
References 2, 3, 10, 14, 21, 29, 30, 41, 47, 57, 66, 67, 69, 82, 85, 86, 89, 96, 114,
138, 145.
The enthusiasm for arthroscopic stabilization of anterior
shoulder instability is based on the assumption that limited
disruption of the anterior soft tissues results in a better func-
tional outcome. This is particularly relevant to young throwing
athletes who require full external rotation and power. Although
short-term studies with 2- to 3-year follow-up are encouraging,
long-term data supporting this assumption are not available.
44,76
However, three recent meta-analyses comparing arthroscopic ver-
sus open repair for traumatic anterior shoulder instability both
concluded that open repair has a more favorable outcome with
respect to recurrence and return to activity.
36,50,98
Because arthro-
scopic management of instability has been in evolution over the
recent years, the conclusions drawn from the meta-analyses may
be biased toward success of open repair.
The technique, which was originally popularized by Johnson,
74
uses a dual-pronged staple and attempts to reproduce the duToit
capsular staple-Bankart repair arthroscopically.
4,42,150
Since then,
modified techniques have included the use of a removable rivet,
154
modified staple capsulorrhaphy,
56
cannulated screw and ligament
washers,
158
and suture Bankart repair.
4,31,99,100
The ideal patient is an individual with posttraumatic, recur-
rent, anterior, unidirectional instability with labral detachment
below the level of the equator of the glenoid. Patients with MDI
are not candidates for this procedure. Routine examination of
patients under anesthesia is performed before the procedure.
Individuals with a significant sulcus sign that does not lessen
with external rotation and adduction are treated with a rotator
interval closure.
One can use a suture technique in which absorbable sutures are
placed through the inferior glenohumeral ligament and a Bankart
repair is achieved through transscapular drill holes.
4,31,99,100
Drill
holes are placed above the equator on the anterior scapular neck
to allow restoration of tension in the inferior glenohumeral liga-
ment as it is pulled superiorly and medially with the repair. More
recently, the use of a biodegradable cannulated tack to avoid
problems associated with hardware or drilling across the scapula
has been discussed.
149
No matter what form of fixation is used, it is essential to ade-
quately prepare the anterior scapular neck to ensure a bleeding
bony bed for the repair. When a motorized burr is used, care
should be taken not to slip over the glenoid rim and injure the
articular surface. Injury to the suprascapular nerve is a theoreti-
cal risk with pin placement through the scapula. Excessive lateral
penetration of the pins should be avoided.
100
In conclusion, many pitfalls and complications are poten-
tially encountered in surgery for shoulder instability. The shoul-
der surgeon must have an organized approach to diagnosis and
treatment. If surgery is contemplated, the procedure must be
tailored to the individual patient and must deal with the under-
lying pathology.
FRACTURES AND DISLOCATIONS ABOUT
THE SHOULDER
Fractures and dislocations about the shoulder are very common
injuries. These injuries are best classified by anatomic location
for the purpose of discussion. Shoulder girdle injuries are located
at the sternoclavicular joint, clavicle, acromioclavicular joint,
proximal end of the humerus, and scapula. An associated neu-
rovascular injury may or may not be present.
Sternoclavicular joint
Most often, sternoclavicular dislocations do not cause any signifi-
cant functional disability.
24
An anterior dislocation is usually
asymptomatic and does not require any treatment. Posttraumatic
ankylosis of the sternoclavicular joint can cause pain and disabil-
ity. Compression of the mediastinal structures can occur with pos-
terior dislocations of the sternoclavicular joint. In general, anterior
injuries can be treated conservatively and posterior injuries may
require some intervention. Surgical management of chronic stern-
oclavicular dislocations may include soft tissue reconstruction,
arthrodesis, resection of the medial aspect of the clavicle, and
resection combined with costoclavicular ligament reconstruction.
Clavicle
Clavicular fractures account for greater than 60% of shoulder
girdle fractures. The middle third of the clavicle is involved in
82% and the distal third in 15%.
128
Nonunion of the clavicle is
relatively uncommon and reported in 1.8% of those patients
treated nonoperatively.
128
If a nonunion does occur, most often
it is minimally symptomatic. One study has determined that
atrophic nonunions are less likely to become symptomatic than
are hypertrophic nonunions.
155
In a study by Johnson and
Collins,
73
26 clavicular nonunions treated nonoperatively
resulted in 23 excellent results, 2 good results, and 1 poor result.
Rowe
128
noted spontaneous uniting of apparent nonunions as
long as 5 months from the time of injury. Only patients with sig-
nificantly symptomatic nonunions and malunions should be
offered reconstructive surgery.
Malunion of the middle third of the clavicle, if symptomatic,
can be managed with osteotomy and bone grafting. This is sup-
plemented with internal fixation. Nonunions can be managed by
excision of the pseudoarthrosis, reduction, bone grafting, and
internal fixation with promising results.
75,110
Distal clavicular
nonunions, which can result after type II distal clavicle fractures,
have been treated by excision of the distal fragment and/or open
reduction and internal fixation. The results of excision cannot be
recommended.
73
Neer
107
documented some success with
transacromial wire fixation. The fixation is removed after union
has occurred. However, cases of migratory hardware have made
pin or wire fixation less appealing.
Acromioclavicular joint
Of shoulder girdle dislocations, 9% involve the acromioclavicu-
lar joint. Fifty percent are complete grade III or higher disloca-
tions with disruption of the conoid and trapezoid components
of the coracoclavicular ligaments.
128
Most acute acromioclavicular injuries can be treated non-
operatively: application of ice over the first 24 hours, possibly a
sling for comfort, and resumption of activity at approximately
1 week if tolerated. Posterior displacement of the clavicle is
Chapter 5d Fractures and dislocations about the shoulder 189
uncommon and may require surgery to reduce the clavicle.
It may be wedged into the angle between the acromion and the
spine of the scapula. One may attempt a closed reduction by
displacing the shoulder posteriorly to widen the distance
between the acromion and sternum.
Treatment of injuries that involve complete separation of the
acromion and clavicle is controversial. Some have attempted closed
reduction with pressure by tape or a splint, but significant problems
with the skin have been noted when these techniques are used.
Surgery for acute grade III lesions has included many techniques
105
:
direct acromioclavicular joint stabilization with ligament repair;
clavicle stabilization by attachment to the coracoid, as with a
Bosworth screw, wire, Dacron tape,
58
silk sutures, or absorbable
suture; and resection of the outer end of the clavicle and coracoclav-
icular ligament stabilization with the coracoacromial ligament.
151
Most patients with chronic acromioclavicular subluxations or
dislocations are asymptomatic or minimally symptomatic and
respond well to nonoperative management. Occasionally, acromio-
clavicular subluxations become symptomatic.
105
Degenerative joint
disease or osteolysis of the distal end of the clavicle may develop.
These problems can be assessed with an acromioclavicular view on
plain radiographs and by injection with local anesthetic to confirm
the diagnosis with pain relief.
Proximal humerus fracture dislocations
The classification of proximal humeral fractures is based on the
absence or displacement of each of four major segments:
the humeral head, the greater and lesser tuberosities, and the
humeral shaft. The Neer classification is most commonly used
and considers the segment displaced if there is greater than
45 degrees of angulation or 1 cm of displacement. It should be
noted that all patients with a suspected fracture of the proximal
end of the humerus require a shoulder trauma series of radi-
ographs. This includes anteroposterior, lateral, and axillary views.
The treating physician must exclude concomitant dislocation of
the humeral head. A complete vascular and neurologic examina-
tion must be performed and documented.
Treatment considerations include the patients age, functional
demands, dominance, expectations, anticipated compliance,
degree of segment displacement, and bone quality. Most of these
fractures can be managed with protective immobilization and
early range of motion. This is, of course, based on the aforemen-
tioned factors and includes fracture stability. In a prospective ran-
domized study of proximal humerus fractures (minimally
displaced), Kristiansen et al
79
compared 1 and 3 weeks of immobi-
lization before starting physical therapy. Shorter immobilization
resulted in better functional results during the first 3 months. After
6 months, the results in both groups were essentially the same.
Fractures that are more significantly displaced require reduc-
tion. This can be accomplished by closed means or with open
reduction and internal fixation. Occasionally, prosthetic replace-
ment is preferred. Available internal fixation includes tension band
wires, screws, percutaneous pins, plates and screws, and
intramedullary nailing. There is a trend toward open reduction
and internal fixation as newer types of locking plates become more
commonly implemented.
45
This restores anatomy and provides
fracture stability. The risk of avascular necrosis increases with
fracture comminution and displacement, but conversion to hemi-
arthroplasty is always a possibility after attempted fracture fixation.
Two-part lesser tuberosity fractures are often associated with
posterior glenohumeral dislocation. Smaller fragments can be
treated nonoperatively: Larger fragments may require open reduc-
tion and internal fixation. Two-part greater tuberosity fractures may
include a tear of the rotator cuff. This requires open reduction and
internal fixation with either a tension band wire or screw and repair
of the rotator cuff tear. Two-part fractures of the anatomic neck are
uncommon and carry a significant risk of osteonecrosis. Flatow et
al
48
published a series of 12 two-part greater tuberosity fractures
that were treated surgically by open reduction and internal fixation
with a heavy nonabsorbable suture and careful repair of the rotator
cuff. All fractures healed, and early range of motion resulted in
good or excellent results in all patients.
Two-part surgical neck fractures can be either impacted or
completely displaced and unstable. Options for treatment
include closed reduction, with or without percutaneous pinning,
or open reduction and internal fixation. Kowalkowski and
Wallace
78
published a series of 22 displaced fractures treated with
closed percutaneous Kirshner wire stabilization of the surgical
neck. Significant problems in obtaining adequate reduction and
migration of the smooth pins were encountered. Unsatisfactory
results were more common in the older age group (greater than
50 years old).
In three-part fractures, closed reduction is often difficult to
maintain, and therefore open reduction is required. Tension-
band wiring can often be used because it incorporates the rota-
tor cuff in the repair. If the fracture is severely comminuted or
the bone osteoporotic, a hemiarthroplasty can be considered,
especially in elderly patients.
In young patients with a four-part proximal humerus fracture,
an attempt at open reduction and internal fixation is considered
despite the high risk of osteonecrosis. If reconstruction is not
possible or the patient is elderly and has poor bone stock, a
hemiarthroplasty is preferred.
As discussed earlier, it is important to eliminate the presence
of concomitant dislocation of the humeral head. Isolated disloca-
tions without fracture can be seen. Many posterior dislocations of
the humeral head are missed and recur chronically. These patients
most often complain of decreased range of motion. They may or
may not complain of pain. Articular impression fractures can
often best be imaged with computed tomography. In general,
closed reduction can be considered if the injury is less than 6
weeks old; after 6 weeks, open reduction is required. Treatment
of the articular impression defect is based on the percentage of
head involvement. If the defect is less than 20%, it is generally
stable after a period of immobilization. If the defect is between
20% and 40%, a transfer procedure into the defect may be
required, as well as possibly a subscapularis transfer for posterior
dislocations or infraspinatus transfer for anterior dislocations.
A hemiarthroplasty may be used if the defect is greater than 40%
of the head or if significant degenerative changes are present.
FROZEN SHOULDER
Frozen shoulderalso termed adhesive capsulitishas many under-
lying causes. It can be seen in association with other shoulder
pathologies, for example, posttraumatic, postsurgical, and
rotator cuff pathology. It is also associated with other disease
entities, including insulin-dependent diabetes mellitus, parkin-
sonism, cardiovascular disease, and thyroid disease.
Most patients have an insidious onset of pain and stiffness.
Most patients demonstrate a gradual decrease in pain and return
of motion over time. There may be improvement for up to
24 months. Treatment consists of gentle physical therapy, antiin-
flammatory medication, and occasional use of cortisone injec-
tions intraarticularly and subacromially. If the patient does not
respond after an extended trial of therapy, consideration may be
given to manipulation under anesthesia. More recently, arthro-
scopic release and debridement have been proposed.
153
Open
surgical release is rarely indicated and may in fact worsen the
problem. Ozaki et al,
117
however, reported on 17 patients treated
surgically for recalcitrant adhesive capsulitis. These patients
showed significant contracture of the coracohumeral ligament
and rotator interval. Resection of these structures relieved pain
and restored motion.
DEGENERATIVE JOINT DISEASE OF THE
SHOULDER
Degenerative joint disease of the shoulder can occur secondary
to a number of different underlying pathologic conditions. The
glenohumeral joint requires prosthetic replacement less often
than other major joints. Osteoarthritis of the glenohumeral
joint is uncommon, and patients with rheumatoid arthritis can
most often be managed nonoperatively with regard to the shoul-
der. Degenerative joint disease may develop after fracture of the
proximal humerus and subsequently require treatment. In rare
cases, proximal humerus fractures may necessitate prosthetic
replacement.
Any of the aforementioned pathologic entities may be an
indication for shoulder replacement. It is, however, most useful
for diseases in which the proximal humeral subchondral bone
has become distorted and the articular surface destroyed result-
ing in painful decreased motion. All patients should pursue a
nonoperative course of management initially. Should symptoms
persist or progress symptomatically, surgical intervention can be
contemplated.
Although shoulder prosthetic systems have improved, the
patient may be a candidate for arthrodesis. This can be consid-
ered in a younger active patient with degenerative arthritis, joint
sepsis, or loss of deltoid and rotator cuff function or as a salvage
procedure after failed total-joint arthroplasty.
The humeral component is designed to preserve metaphyseal
bone stock and provide adequate fixation. The glenoid compo-
nent is often not required, particularly if the rotator cuff is intact
or repairable. Hemiarthroplasty is usually considered in younger
patients with osteoarthritis, posttraumatic conditions without gle-
noid loss, rotator cuff pathology, or osteonecrosis. In many
patients with more extensive osteoarthritis and rheumatoid arthri-
tis involvement, glenoid resurfacing has improved pain relief. The
glenoid most commonly is cemented into position. In younger
patients with good bone stock, consideration is given to unce-
mented glenoid fixation with bone ingrowth. Results of survivor-
ship analysis predicted a 27% failure rate.
23
Other studies reported
excellent pain relief with total-shoulder arthroplasty.
51,152
Reverse-type prostheses are reserved for the elderly person with
severely debilitating cuff tear arthropathy or loss of the cora-
coacromial arch. However, early reports are fraught with a high
complication rate, and its implementation is still being
defined.
83
CONCLUSION
In attempting to treat the myriad of shoulder problems, the
orthopedist must first make an accurate diagnosis. The goals of
treatment include controlling symptoms, improving function,
and preventing recurrence, if possible. A systematic approach to
management includes appropriate conservative modalities and
surgical intervention, if necessary. Future concerns must address
cost-effectiveness, standards of care, and outcome research.
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EXPOSURE-RESPONSE RELATIONSHIP
It is necessary to understand in general and specific terms the rela-
tionship between work factors and conditions that affect fatigue
and risk of musculoskeletal disorders (MSDs). This relationship is
referred to as the exposure-response relationship.
4,34,35
Figure 5e.2
shows a hypothetical exposure-response relationship with expo-
sure on the horizontal axis and response on the vertical axis.
A number of metrics have been proposed and used for describ-
ing exposure; some of these are described later in this section.
Response is typically expressed as the prevalence of symptoms
or conditions at a given time or as an incidence rate of cases
over time.
Exposure-response relationships typically exhibit a sigmoid
relationship as exposure increases from low to high. The preva-
lence and incidence of MSDs at low exposures are referred to as
the background level and may be due to personal or other non-
work factors. The prevalence and incidence may also vary from
one sign, symptom, condition, and measurement method to
another. Figure 5e.2 illustrates two examples: curve a shows a low
background level and a high sensitivity to work factors and curve
b shows a high background level and a low sensitivity to work
factors.
In the future, we will have sufficient data to specify job designs
for given populations that will produce an acceptable level of
risk. Until then, the exposure-response relationship still provides
important insights for job designers.
Exposure-response relationships are based on a series of bio-
mechanical and physiologic mechanisms.
4,34,35
Work activity
entails exertion of the body to overcome the weight, resistance,
and inertia of work objects. These forces produce moments
about joints that must be counteracted by muscles. The position
of the body and the external forces are exposure variables and
the moment about the shoulder is a response variable. At a
second level, the joint moments can be regarded an exposure
variable, whereas the muscle force acts as a response variable. At
a third level, muscle forces can be regarded as exposure variables
and perceived exertion, discomfort, and fatigue as short-term
for Shoulder Disorders
Thomas J. Armstrong
This chapter is concerned with workplace adaptations for
preventing work disability due to shoulder, neck, and elbow
impairments. Disability occurs when work demands exceed
worker capacities (Fig. 5e.1).
3,9
Development of workplace adap-
tations requires information about both worker and job demands,
which can then be compared to determine whether new or addi-
tional adaptations are required. Although population work capac-
ity data can often be determined from published data and
models, individual data must be obtained from a qualified health
care provider. The health care provider plays an important role
also in determining how successful intervention has been and
whether additional job modifications are required. Development
of workplace adaptations requires the affected worker, the health
care provider, and the employer to work closely together.
Although the concept of disability is straightforward, its
determination of disability and the development of adaptations
are more complex due to the multiple physical, behavioral, and
social variables involved. It is possible unwittingly to declare a
worker disabled who is not or to declare one able who is not.
It may be found, for example, that a worker is disabled because
of a shoulder impairment that restricts his or her reach capacity,
but that worker might have learned to adapt the workplace by
rearranging equipment or standing up to reach distant objects.
Similarly, it may be found that a worker is able to reach all the
necessary work objects but is disabled by inability to do the job
for 8, 10, or 12 hours per day.
C HA P T E R
5e
Demands
>
capacities
Successful adaptation
Disability
Modify job
Determine job
demands
Treat worker
Evaluate
worker
No
Yes
Figure 5e.1 Basic process for accommodation of work populations or
individual workers.
Exposure
R
e
s
p
o
n
s
e
b
a
Figure 5e.2 General exposure-response relationship shows an
increasing prevalence or incidence of pain, fatigue, or other
musculoskeletal disorders with increasing frequency and duration of
force and posture. Curve a illustrates a low background level and a
high sensitivity to a given factor and curve b illustrates a high
background level and low sensitivity to a given factor.
Chapter 5e Workplace adaptation for shoulder disorders 196
response variables. Chronic tissue injuries and corresponding
symptoms can be regarded as long-term responses. These biome-
chanics and physiology relationships are supported by experi-
mental, psychophysical, and epidemiologic studies.
4,34,35
Biomechanics
An important example of the exposure-response relationship is
found in the shoulder, the examination of which provides useful
tools for developing workplace adaptations. By Newtons Third
Law, when a worker reaches for an object, the muscles in the
shoulder and elbow must produce sufficient moment forces of
gravity on the arm, forearm, and hand (Fig. 5e.3). A work object
in the hand requires additional muscle force. The load moment
on the shoulder, M
s
, can be calculated based on the size of the
body parts and their weight
13,36
:
M
s
= cos
1
x
1
w
1
+ (cos
1
l
1
+ cos
2
x
2
)w
2
+
(cos
1
l
1
+ cos
2
l
2
+ cos
3
x
3
)(w
3
+ w
object
)
where l
1
, l
2
, l
3
are lengths of the arm, forearm, and hand;
1
,
2
,
3
are angles of the arm, forearm, and hand with respect to
M
tot
W
object
W
3
X
3
I
3
W
1
X
2
I
2
W
1
X
1
I
1 A
B
q
1
q
3
q
2
Figure 5e.3 (A) The moment produced about the shoulder is equal to the sum of the moments produced by the arm, forearm, and hand. In
addition, the weight of a work object such as a part or tool contributes to the shoulder moment. (B) The angles of the arm, forearm, and hand with
respect to the horizontal are shown.
Chapter 5e Exposure-response relationship 197
the horizontal; x
1
, x
2
, x
3
are the moment arms between the prox-
imal joint and the center of gravity of the arm, forearm, hand,
and work object; and w
1
, w
f2
, w
3
, w
object
correspond to the weights
of the arm, forearm, hand, and work object.
The moment arms can be measured for a given individual
or estimated from height of a given population percentile using
the relative link lengths shown in Table 5e.1a
16
and the link
center of gravity locations shown in Table 5e.1b.
15,29
Weights of
each segment can be estimated for a given individual or popula-
tion percentile weight using the relative segment weight data
shown in Table 5e.1c. Height and weight data for the U.S. adult
population are shown in Table 5e.2.
The calculated shoulder and elbow moments for persons
with average female and male stature and weight performing a
horizontal reach at elbow height and at shoulder height are shown
in Figure 5e.4. Figure 5e.4, b, d, f, and h, shows how the moment
about the shoulder due to the weight of the arm, forearm, and
hand increases with the horizontal reach distance. Added to the
weight of the arm, forearm, and hand, the moment of the weight
of a held object such as a tool or part would equal the distance
between the shoulder and hand times the weight. Holding a 10 N
(2 pound) tool in the hand at a distance of 0.6 m, for example,
would add 6 Nm to the 10 Nm of the arm and forearm.
This simple biomechanical analysis can be applied to many
work tasks. Figure 5e.4, for example, shows a 7-Nm shoulder load
in the shoulder of an average female holding her hands over a
keyboard at a distance of 0.5 m, with the moment proportionally
Table 5e.1a Average body link sizes as fractions of
total stature
16
Link Fraction
Stature 1.000
Floor-ankle 0.039
Floor-knee 0.285
Floor-hip 0.530
Floor-shoulder 0.818
Floor-elbow 0.630
Floor-wrist 0.485
Floor-hand 0.377
Floor-buttocks 0.480
Floor-eye 0.936
Center-shoulder 0.129
Shoulder-elbow 0.188
Elbow-wrist 0.145
Wrist-hand 0.108
Table 5e.1b Body segment distance from proximal
joint center of gravity
15
Link Center of gravity
Arm 43.6%
Forearm 43.0%
Hand 50.6%
Table 5e.1c Body segment weights as percentages
of total body mass
15,29
Link Relative body mass
Head 6.9%
Arm 2.7%
Forearm 1.6%
Hand 0.6%
higher for a worker with greater body weight. The biomechanical
analysis provides both a qualitative and quantitative rationale for
job design.
Important limitations
Deliberately simplified for demonstration purposes, this analysis
of shoulder stress generally underestimates the actual loads.
Increased loads result from inertial forces associated with acceler-
ation and deceleration of the body and work object. Additional
loads may result also from antagonistic muscle forces. Although
some antagonistic muscle contractions are inevitable, others may
result from psychologic stresses,
7
the contributions of which,
although real, are difficult to quantify and beyond the scope of
this discussion.
Other biomechanical considerations
In addition to the effect on muscle workload, increasing shoul-
der angles produce pressure on internal and surrounding soft
tissues.
22
In fact, although the required muscle loads actually
decrease as the arm torso arm angle exceeds 90 degrees, pressure
on soft tissues continues to increase. Epidemiologic studies show
that elevated elbow postures are associated with elevated incidences
of chronic shoulder pain and impairment.
6
Other body parts
Similar analyses can be performed for other parts of the body,
such as the neck.
23
Bending the neck or torso forward to reach
or see work objects such as documents, controls, or equipment
produces load moments on the neck that must be counteracted
by internal muscle forces. Extreme rotation of the forearms in
combination with forceful exertions of the hands produces stress
on the attachments of the finger flexor and extensor muscles.
As a general rule, jobs should be designed so that workers do not have
to perform sustained or repeated exertions at or near range of motion
limits. Ideally, the elbows should be near the sides of the body,
the forearms should not be rotated to one extreme or the other,
and the head should be held upright. At the other extreme, the
work pace should enable workers to periodically stretch and
change positions. Even the best posture eventually becomes
uncomfortable if it is maintained too long.
Localized fatigue
Acceptable work design standards for preventing MSDs that
may afflict the elbow, neck, and shoulder have not been estab-
lished, but recommendations may be made for preventing local-
ized fatigue. An important problem in its own right, localized
fatigue may be a harbinger or precursor of more serious MSDs.
34,35
According to the above exposure-response relationship, localized
fatigue responses include concentrations of metabolic substrates,
metabolites, and ions. These changes may result in altered
electromyograms, reduced motor control, reduced strength, and,
perhaps most importantly, pain. Exposures are expressed as
percentages of maximum voluntary contraction (% MVC), exer-
tion frequency, and duty cycle. The % MVCs are computed
as the ratio of the required muscle force to that possible for a
given task, individual, or population or as the ratio of job demands
to worker capacities, as shown in Figure 5e.1. Recommended
acceptable exposure limits for continuous work previously ranged
from 0 to 15% MVC; those for intermittent work range from
17% to 21% MVC. Bystrom and Fransson-Hall
10
recommended
an upper limit of 10% MVC for continuous static work and 17%
MVC for intermittent work. The above biomechanical analysis
of the shoulder loads during reaching and lifting can be used to
estimate relative muscle workload for a given task, but first it is
necessary to consider worker capacity.
Worker capacity
Acceptable workloads vary from group to group and person to
person, and design commonly accommodates the general popu-
lation or a specific individual. In the former case, work capacity
data are typically taken as a lower percentile of the general pop-
ulation. It is all too common to design for a 5th percentile, a
practice that seems to be reinforced by reference books showing
the 5th percentile, average, and 90th percentile population data.
The problem is that 5 people out of 100 may be disqualified or
experience significant difficulty or injury doing the job.
Design for an individual requires a function evaluation that
specifies strength limits for that person. The designer should work
closely with the evaluator during and after design implementa-
tion to make sure that the job can be performed without risk of
injury or reinjury. For discussion purposes, data from Winters
and Kleweno,
40
shown in Figure 5e.5, indicate that female
strength is about half that of male strength and that male
strength is sensitive to shoulder posture. The average female
strength of approximately 30 Nm is significantly less for an
elderly or injured worker. Reaching results not only in increased
load moments on the shoulder (Fig. 5e.4) but also in decreasing
strength (Fig. 5e.5). Vertical reaching also reduces strength.
Figure 5e.6 shows a job in which a female of average stature,
proportions, and weight gets 10 N parts at a rate of 20 per
minute from a rack at a distance of 0.625 m at shoulder height
and places the parts on a moving tray at a distance of 0.32 m.
Because the trays are moving, the worker cannot rest her fore-
arms while waiting for them to come into position. The shoulder
moments due to the weight of the body and load are calculated
in Table 5e.3 and are plotted in Figure 5e.6B. (Loads between
successive positions are approximated as straight lines.) It can be
seen that the moments increase due to the weight of the arms
during the reach. The moment then increases as the part is lifted
and then decreases as it is moved into position to wait for the
tray to come into position. Finally, the load force decreases to
zero as the load is released, but the shoulders must continue to
support the weight of the body. The average total shoulder
moment can be calculated as a time-weighted average:
where M
s
is the average shoulder moment, t
i
is the duration of
the ith work element, and M
i
is the average total moment produced
during the ith element.
For this sample task the average moment is calculated as
= [0.67 (4.5 + 9.8)/2 + 0.13 9.8 + 0.79
(16.05 + 7.71)/2 + 2.00 7.71 + 0.36 7.71 + 0.07
(7.71 + 4.5)/2]/4.0 = 8.4 Nm
This analysis provides important insights into the factors that
should be considered in evaluating and designing work stations. It
is important to know the locations of controls and those where
materials, parts, and tools are stored and used as well as the forces
required to obtain, hold, and use work objects. The list of work
elements and their durations
33
are likewise all significant factors
affecting the load on the shoulder and other parts of the body.
As described earlier, loads on the body are frequently normal-
ized as a fraction of maximum strength or percent of maximum
voluntary contraction, % MVC, which is used commonly as a
metric of physical workload and predictor of localized fatigue.
Calculation of relative workload requires information about
both the absolute load and the corresponding work strength.
Strength varies among workers, joints and their relative positions,
hands, ages, and occupational groups and may be affected by
fatigue, injuries, and diseases. The analyst may select a value
from the literature that corresponds to the population of interest
or use data provided by a functional evaluation of a specific
worker of interest. Based on an average strength of 30 Nm, the
average relative workload for the worker described in Figure 5e.5
and Table 5e.3 would be 28% MVC.
Joint loads can be estimated also from surface electromyo-
graphy (EMG), which can be regarded as a response variable
M
t M
t
s
i i
i
=

( )
Table 5e.2 Statures (m) and body masses (kg*) for males and females ages 18 and over from the National
Center for Health Statistics
11
Female Male
Average 5% 50% 95% Average 5% 50% 95%
Stature 1.618 1.504 1.618 1.73 1.755 1.636 1.755 1.880
Weight 69.2 48.0 65.6 102.5 82.1 59.7 80.0 110.8
*1 N = kg 9.8 m/s
2
.
Chapter 5e Exposure-response relationship 199
14
12
10
8
6
4
2
0
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8
Distance (meters)
Male F
M
o
m
e
n
t

(
N
m
)
0
10
20
30
40
50
60
70
80
90
100
0.40 0.40 0.20 0.20 0.00 0.80 0.60
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
14
12
10
8
6
4
2
0
2
4
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7
Distance (meters)
Female D
M
o
m
e
n
t

(
N
m
)
0
20
40
60
80
100
120
140
160
14
12
10
8
6
4
2
0
2
4
6
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7
Distance (meters)
Male Male B A
0.40 0.40 0.20 0.20
Female
0.00 0.80 0.60
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
C
0.00 0.40 0.20
Male
0.80 0.60
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
E
14
12
10
8
6
4
2
0
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8
Distance (meters)
Female H
M
o
m
e
n
t

(
N
m
)
0
10
20
30
40
50
60
70
80
90
100
Shoulder moment
(Nm)
Shoulder angle ()
Shoulder moment
(Nm)
Shoulder angle ()
Shoulder moment
(Nm)
Shoulder angle ()
Shoulder moment
(Nm)
Shoulder angle ()
0.00 0.40 0.20
Female
0.80 0.60
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
G
M
o
m
e
n
t

(
N
m
)
0
20
40
60
80
100
120
140
160
Figure 5e.4 Calculated shoulder and elbow moments due to the weight of the arm, forearm, and hand for an average male and female
performing a horizontal reach at elbow (A-D) and at shoulder (E-H) heights for females (C, D, G, H) and males (A, B, E, F).
20
15
10
5
0
0 1 2 3 4
Time (s)
S
h
o
u
l
d
e
r

(
N
m
)
Total (Nm)
Load (Nm)
Body (Nm)
Average
A B
Figure 5e.6 (A) A worker reaching 0.625 m forward to get 10 N (2 pounds) parts from trays 0.320 m in front of her on a moving tray and a rate
of 20 per minute. (B) The moment due to the weight of the body and work object are shown. Average total moment (body plus work object) is
8.4 Nm for the work cycle.
to external load.
23,26,31
Generally, EMG methods are used to
verify hypotheses developed using biomechanical analyses and
psychophysical studies. Electrodes are attached over one or more
of the muscles associated with the joint motion of interest and
connected to appropriate preamplifiers, amplifiers, data loggers,
and computers. The test can be normalized with respect to a
maximum exertion or some other reference signal and provide a
continuous real-time indication of muscle load. Further discus-
sion of EMG methods is beyond the scope of this chapter.
ANALYSIS OF JOB TASK DEMANDS
As stated at the beginning of this chapter and shown by the above
discussion, information about task demands is necessary for
disability evaluation and work adaptation design. Collecting
job and worker information requires a systematic approach in
two steps.
Job task demands
The first step documents what, where, when, and how the job is
performed and includes the process, equipment, procedures, and
environment.
Job documentation
A thorough documentation of the job helps to ensure a sys-
tematic analysis of all relevant factors and enables the analyst
to identify those that contribute to stressful postures. Finding
that the job involves exposures to extreme shoulder postures, for
example, is insufficient without information explaining what
actions like reaching for a part or operating a control produce
those postures. This information enables the analyst to recom-
mend possible interventions to reduce that stress. Evaluation of
particular stresses, such as part weight and location, can be used
to calculate the load moment on the shoulder.
Observations
Documentation procedures may need to be adapted to the type
of jobs being studied. In many settings, particularly manufactur-
ing, the work is by design standardized to control work quality
and production, but subtle differences from worker to worker
may depend on their sizes, methods, and skill levels. A short
worker, for example, may have to reach up and over, whereas a
tall worker may have to reach down and under. One may choose
100
80
60
40
20
0
0 30 60 90 120
Females
Males
M
S

(
N
-
m
)
Figure 5e.5 Shoulder strength for four healthy young females and
four healthy young males versus shoulder angle with elbows straight
(triangles) and flexed 90 degrees (circles).
Chapter 5e Analysis of Job Task Demands 201
to walk around a pallet of parts, whereas another reaches across.
Although one worker may be able to complete work promptly
and take brief rest periods, another may have trouble keeping up
and have no rest.
How workers perform their jobs may change over time.
In some cases, jobs contain multiple tasks, as though each was
two or more jobs. The documentation should include identifi-
cation of each task, its frequency, and its duration. Frequencies
and duration may vary from day to day, so it is necessary to
either observe the job over time as previously described or to ask
the worker or supervisor to estimate the variation.
An increasing trend to rotate workers among jobs occurs in
many cases to maintain production schedules by cross-training
them to deal efficiently with absenteeism and schedule changes.
In other cases it is done to reduce exposure to highly demanding
jobs. Generally, the analyst performs at least a cursory analysis of
all the jobs the worker performs, particularly if he or she has had
a musculoskeletal injury.
It is common to manufacture different product models or
even products on the same production line. In some cases the
worker may have to hurry to perform all the required assembly
operations without rest, whereas at other times they may be able
to work quickly and rest frequently.
Some jobs, such as maintenance, repair, and office work,
have yet to achieve a high level of standardization and instead
typically entail two or more tasks that may be performed at
irregular intervals for variable periods. These multitask jobs
may require considerably more time than a standardized single-
task job.
For the above reasons, observations should be repeated for
several workers over time to assess job variations for those being
studied. While interviewing workers, the analyst should antici-
pate this variability. Differences from one worker and one work
station to the next often provide insights into how the job can
be improved.
The documentation can be performed from available job
descriptions, time studies, workplace inspections and measure-
ments, equipment specifications, and interviews with workers
and supervisors. To facilitate cooperation of both the worker
and employer, it is important that the job analysis minimizes
disruption of work activities. Because the goal is to obtain infor-
mation about how the job is performed under normal work
conditions, minimal disruptions will help keep the worker from
being distracted by the analyst.
Available information may include job descriptions from the
personnel department, standard work method descriptions, and
time analyses from industrial engineering or previous ergonomic
assessments. Job descriptions from the personnel department
tend to focus on skill requirements rather than on force and
posture patterns. Work method and time descriptions can be
quite useful because they usually describe the methods and time
allocations. Combined with information about work objects
and work stations often make it possible to predict loads and pos-
tures as described above. Because the job may have changed since
the standard was developed, work method and time descrip-
tions should always be verified with observations or interviews.
Although in some cases an ergonomic job analysis has previ-
ously been performed, at present such analyses are not
standardized. Unless the analyst has first-hand knowledge of the
job and the methods used to analyze it, each job should be
inspected to verify that all necessary information was included
or that it has not changed.
Video recordings
Still and video images have become integral parts of job analyses.
Readily available low-cost digital and video cameras can now
be used to collect images and transfer them into computers
where they can be viewed and edited. Freeware, such as Apple
Computers QuickTime, can be used to play back digital films
frame by frame, the most useful of which can be captured and
pasted into report documents. A few simple steps will greatly
improve the quality of the video data: (1) obtain permission
from the worker and the employer, preferably in writing;
(2) record several representative work cycles, both to allow the
worker to get used to the camera and to observe variations;
(3) take pictures from several angles (the view of one hand may be
blocked by the body or other obstructions); and (4) use a tripod
to improve video steadiness most efficiently and least expen-
sively. Video cameras often can be set up and left to run unat-
tended, even with intermittent pauses at specified intervals.
24
If video recordings are not possible, the analyst may elect to
make periodic tours of the workplace to observe and record
personally.
Intermittent observations of worker activities are referred to
as work sampling; statistical procedures have been described
for estimating confidence limits for the frequency that a task
occurs.
17,33
To get a confidence limit of a few percent, typically
hundreds of samples are required, which may be beyond the
scope of most studies. Statistical calculations are based on the
assumption that the observations are randomized. Although
generally there is sufficient variation in the work process to
allow fixed interval sampling, the analyst should make sure that
Table 5e.3 Work elements, locations, and loads for a repetitive hand transfer task
Work element Elapsed time Hand location Load weight Moment load Moment body Total
Reach 0.67 32.162.5 0 0 4.59.8 4.59.8
Grasp 0.13 62.5 0 0 9.8 9.8
Move 0.79 62.532.1 10 N 6.253.21 9.84.5 16.057.71
Wait 2.00 32.1 10 N 3.21 4.5 7.71
Position 0.36 32.1 10 N 3.21 4.5 7.71
Release 0.07 32.1 0 0 4.5 4.5
observations are not synchronized from any workplace activities
that could bias the results.
Measurements of the work station and equipment
Physical measurements of the work station often can be made
before or after the shift or while the worker is on break. The
employer may have engineering drawings that enable the analyst
to determine key dimensions such as the height of the work
surface and the location of parts, assemblies, and controls;
otherwise, it will be necessary to determine these dimensions
using a tape measure. In either case it is necessary to establish
reference lines or planes for these measurements. The ideal refer-
ence plane for vertical measurements for a vertical worker, for
example, is the floor. The ideal horizontal reference plane is a
vertical plane that passes through the barrier separating the
worker from the work object. For a seated worker, this is the front
of the desk, whereas for a standing worker reaching into a bin
of parts it is the edge of the bin. The reference plane for hori-
zontal measurements should correspond to a barrier that restricts
movement from side to side. For a worker seated in a fixed loca-
tion, this may correspond to the sagittal plane of the body; if
the worker is standing and free to step side to side, then meas-
urements to either side may not be of critical importance, unless
the worker is required to reach two objects with opposite hands
at the same time.
Interviews
Worker and supervisor interviews are important sources of infor-
mation, the quality of which can be greatly improved with a few
rules
32
: (1) explain the purpose of the interview, (2) list the key
points to be covered, (3) avoid leading questions, (4) clarify by
summarizing back to the interviewee, (5) do not let the interview
wander into irrelevant areas, (6) protect the interviewees confi-
dentiality, and (7) take careful notes or use an audio recording
device. Interviews may be performed with one or more workers
at a time. Questionnaires also can be used to obtain information
from workers and supervisors, but development of a valid ques-
tionnaire to obtain desired information about a given job can
be a major undertaking in its own right. Table 5e.4 is intended
as a template for a job documentation data collection form that
the user can modify to suit specific needs.
Physical job stresses
The second part of the analysis assesses the physical job stresses.
As mentioned at the beginning of this chapter, exposure-response
entails a cascading series of relationships.
4
Job demands may be
characterized as a force and posture profile, as a load moment
profile for a joint such as the shoulder, as the muscle activity
(measured in an EMG), or as a symptom such as localized
discomfort.
Measurement of posture and force
Postures and forces can sometimes be measured directly using
force gauges and goniometers. In the example shown in Figure
5e.6, the major forces are due to the weight of the work object
and that of the upper limb. However, many cases are not this
simple: The worker may lift, push, and pull, for example, at the
same time or push and pull quickly, creating an inertial factor.
Direct weight and breakaway force measurement may be a start-
ing point, but often second- or third-level methods such as
EMG or perceived exertions are also necessary.
Joint angles between two adjacent body segments can be
measured using goniometers, including manual devices that
require the worker to stop while they are positioned over joints
and electrical devices that can be attached to a data logger or
computer for continuous posture recordings. Gerr et al
20
described the use of manual goniometers for determining major
body angles in computer users.
Joint angles can also be estimated from direct observations of
workers or indirect observations of photographs and movies.
Observations are subject to observer and parallax errors.
30
Parallax errors can be minimized by aligning the viewer with
the axis of joint rotation. Often this is not possible; however,
an experienced job analyst can often do an adequate job of
mentally compensating for parallax errors. It is helpful to observe
or record images from several views.
Joint moments can be calculated from loads and body
positions. Recall that moments are related to both the magni-
tude of the force and the distance between the force and the
center of joint rotation. In some cases, it may be possible to
stop the worker and measure distances using a tape measure.
Sometimes distances can be estimated from dimensions of the
work place. In other cases, they may be estimated from pictures.
In some cases, the forces correspond to the weight of an object
lifted; in others, they correspond to the force to hold or move
one object against another. Then it is necessary to simulate the
workers actions with a force gauge.
Surface EMG
Surface EMG, in which electrodes are placed on the skin over
the muscles of interest, is used most commonly for exposure and
fatigue assessment. Electrodes are connected to preamplifiers,
amplifiers, and some kind of recording device. The signals
may be recorded by a portable memory device that the worker
Table 5e.4 Basic job documentation information can
be obtained from existing job descriptions, interviews,
observations, and physical measurements
For the job
Formal job title (in company documentation)
Informal job title (among workers and supervisors at the work site)
Work objectives (one or more reasons that the job exists)
Job tasks (all worker duties that share a common purpose; tasks may
or may not be separated in time and space)
For each job task
Objective
Tools and equipment (ID, size, weight)
Materials and parts (ID, size, weight)
Methods (step-by-step description in necessary detail of what

the worker does to perform the task)
Work station (sketched or described with key dimensions)
Environment (location and conditions of job)

Chapter 5e Analysis of Job Task Demands 203
wears or by a digital computer. The worker may be tethered to the
computer by wires or connected via radio transmitter. Because
EMG values may change very quickly, it is necessary to record
signals over several representative cycles at high frequencies.
The volumes of data generally dictate the use of a computer and
appropriate software for analysis. Jonsson
26
and Mathiassen and
Winkel
31
described procedures summarizing force patterns using
EMG data that indicate rest/recovery time versus work time. The
investigator must be familiar with human anatomy and with the
operation (including calibration) of the equipment to obtain
meaningful results. An important quality of EMG is that it
provides information about a specific body part under real
work conditions by a real worker; a limitation is that an EMG
provides information about only a very small part of the body.
In some cases additional channels can be used to monitor
multiple muscle groups simultaneously, but this may be too
cumbersome and disruptive in many work situations. Some
EMG measurements can be performed on a subject simulating
some part of or the entire job in a laboratory. Although an
important tool, EMG is an advanced technique for use after
observations and simulations have documented the job and
identified the specific muscle groups. A number of commercial
EMG systems are now available and easy to find on the Internet;
the user is cautioned, however, to understand clearly where and
how the test will be used and to have adequate technical support.
Psychophysical responses
Joint loads can be assessed also using perceived exertion,
8,23
which is affected by localized fatigue. Most commonly it is meas-
ured using a Borg scale of relative perceived exertion (Fig. 5e.7B),
but it may be assessed using visual analog scales also shown
in Figure 5e.7C. On average both work equally well, but some
prefer the Borg scale while others prefer the visual analog scale.
39
One of the important and useful features of perceived exertion
Very
uncomfortable
work
Very
comfortable
work
0
0.5
1
2
3
4
5
6
7
8
9
10
B A
C
Nothing at all
Very, very easy
Very easy
Easy
Moderately hard
Somewhat hard
Hard
Very hard
Very, very hard
13
11
10
12
14
0
1
2
3
4
5
6
7
8
9
15
16 17
Figure 5e.7 Local discomfort patterns can be mapped by asking the
worker to indicate areas on a body part map as shown in A. Localized
and overall discomfort and effort can be quantified using the modified
Borg scale shown in B or a visual analog scale shown in C.
is that it can be measured simultaneously for different parts of
the body.
14
Regional body discomfort patterns can be compared
with workload patterns and with underlying impairments.
Saldana et al
37
described the use of a computer program to
evaluate discomfort patterns in rural letter carriers. Readily appli-
cable to other types of work, this method is particularly well
suited for studying office workers who regularly use a computer.
Studies by Ulin et al
39
showed that perceived exertion associ-
ated with the use of a pneumatic hand tool increases with work
distance from the body and with increasing elevation above the
shoulder and decreasing elevation below the elbow. Krawczyk
et al
27
showed similar results for the hand transfer tasks.
With repeated or sustained exertions, the worker may begin
to experience discomfort. With exertions performed over longer
periods such as days, weeks, or years, the worker may experience
chronic symptoms. The Nordic Health Questionnaire provides a
standardized instrument for collecting work symptom data.
28
Saldana et al
37
demonstrated how a computer could be used to
collect worker symptom data and how these data correspond
with work patterns. Symptom data are easy to collect and require
minimum equipment; the data may be highly variable from one
worker to the next, however, and care is required to avoid bias.
Event-based versus time-based observations
The analysis may be event based with observations recorded
only when an event of interest occurs, such as when a worker
reaches for or uses a work object. Joint loads are plotted as a
function of time in Figure 5e.6, but because the times correspond
with the workers reaching for parts, it is an event-based analysis.
The definition of events is arbitrary: They may correspond to
specific work elements as shown in Figure 5e.6, with only selected
work elements, or with the use of certain tools. The example
shown in Figure 5e.6 is an event-based analysis in which the
events are work elements and straight-line extrapolations are
used between successive events. The selection of events is deter-
mined by the job documentation and the goals of the analysis.
The analysis may also be time based in that the forces and
postures are observed continuously or at specific time intervals.
The corresponding events are then examined to identify the work
factors that cause the extreme force or posture. Forces and pos-
tures may be estimated from observations, measured directly
using force gauges and goniometers, or predicted by biomechan-
ical models and insights. The work sampling method described
above is a time-based analysis of activities, but it could be
combined with force and posture measurements.
Prediction of posture and forces
Figure 5e.4 shows how link data can be used to estimate postures
and forces of males and females of given percentiles at selected
locations. In many cases, the analyst may mentally extrapolate
based on observations and experience. When a tall worker is
seen reaching overhead for a part, for example, it becomes obvi-
ous that a short worker or one with limited mobility will be
even more challenged to perform the same task. The analyst may
want to report not only what was observed, but what might
be observed for another worker.
The moments about the shoulder and elbow can be computed
using the methods described above if additional quantification
is desired. These values can be used to predict and compare
worker endurance at the observed versus modified work stations.
Many third-party biomechanical models available for purchase
or for download as shareware or freeware can be used to facili-
tate analysis of loads on the entire body or on selected body
parts. One commercially available product is the University
of Michigan Three-Dimensional Static Strength Prediction
Program.
13
This program enables the user to enter information
about the location and direction of the load, at which the model
calculates moments and populations for percentiles at each major
joint. The user also can directly enter body part sizes and posi-
tions for a given problem.
WORKPLACE ADAPTATION
The preceding discussion indicates that workplace adaptations
entail reducing load moments by rearranging work objects
and eliminating stressful postures, reducing forces themselves, or
reducing the time that forces must be exerted. Such adaptations
include rearrangement of work space layout and use of lighter
tools or materials, mechanical assistance, and/or body supports.
Placement of work objects
Ideally, work objects such as materials, parts, tools, assemblies,
controls, and data input devices should be placed as close to
the worker as possible at or near elbow height. Aforementioned
studies by Ulin et al
39
found that some workers prefer to use tools
slightly above elbow height, which may provide better visibility,
whereas others prefer them slightly below, which may enable
them to lean into the task at hand. Similarly, Sauter et al
38
and
Grandjean et al
21
showed that most keyboard users prefer posi-
tioning conventional keyboards at or near elbow heights, but
some prefer it slightly higher or lower. Personal preferences
vary significantly from person to person. As shown in Table 5e.2,
worker size varies significantly between and within gender groups.
Individual preferences also vary among workers of the same size
and for the same worker over the course of the day; even the best
position eventually becomes uncomfortable.
Because one-size work station will not fit everyone, it is very
important for each worker to be able to adjust the work station
to his or her own preference. Achieving this flexibility begins
with designing equipment in ways that make such adjustments
easy and convenient. If a mechanic must come to raise or lower
a keyboard, the adjustment probably will not occur as often as
needed. Workers must be trained and encouraged to adjust their
work stations, with periodic inspections to make sure that they
are doing so. A workers failure to adjust a work station upon
inspection may not mean a discipline problem but rather a lack
of training or time, an adjustment for temporary stretch break,
or equipment that is difficult or unsuitable to adjust. It is impor-
tant to discuss these issues with the worker.
Although it is usually desirable to locate work objects close
to the worker, it is not always possible. In many cases the job
may entail work on large equipment, parts from multiple sources,
or use of several tools and controls. Work station design begins
with a thorough knowledge of the work objective, tools, materi-
als, and methods as well as worker size and strength, as shown in
Tables 5e.1a, 5e.2, and 5e.4. Together this information can be
used to map worker reach capabilities or envelopes and to
calculate load moments, as shown in Table 5e.3.
Anthropometric considerations
Figure 5e.8 shows maximum reach envelopes for 5th percentile
female and 95th percentile male statures on horizontal work
surfaces. In one case the arm is outstretched at shoulder height,
and in the second case the shoulder is constrained to -60 degrees
(Re. horizontal). There is nothing sacred about the 5th and 95th
percentiles; universal designs that accommodate all possible
users are preferable. As a practical matter the selection of design
benchmarks is based on costs and benefits, although the cost
of potential litigation can favor inclusion of more users in an
analysis and design. In either case, it is still necessary to have
information about the size of the potential work population or
a specific individual to be accommodated. It is also possible to
estimate the effective work area subject to desired posture con-
straints. The effective work area for the small female shown in
Figure 5e.8d, for example, is approximately 0.48 m
2
. Based on a
straight hand, this calculation disregards any intrusion of the
body into the work space. As a practical matter, the area should
be reduced a minimum of 8% for a relatively lean body. The
reach distance and area would be further reduced if the worker
must hold an object like a mouse or a power tool. Reducing the
reach distance by one-half hand length to allow for gripping
would reduce the effective work area by 24% from 0.48 to 0.36 m
2
.
Adjusting for the incursion of the body into the work area fur-
ther reduces the work area to 0.32 m
2
. Of course the worker can
reach farther, but it would be at the expense of increased shoul-
der and/or back flexion. Although reasonable for short periods,
such increased flexion may be unsatisfactory for prolonged or
sustained work.
Objects that are used continuously or frequently should have
first priority for this space. For a data entry job, for example,
these would be the keyboard, mouse, and source documents.
Objects used less frequently such as a telephone, the computer
CPU, or stored reference documents may be placed at the outer
limits of the reach envelope. A typical keyboard requires 0.1 m
2
of
space, a mouse another 0.1 m space, and a standard 8.5 11-inch
document another 0.6 m
2
, totaling 0.26 m
2
of the available
0.32 m. The areas required for the keyboard, mouse, and docu-
ments, however, are not contiguous, and workers generally posi-
tion them in a way that conforms with their body positions.
As a result the 0.32 m
2
will be more than used up.
The required space can sometimes be reduced by selecting
alternative equipment. A track ball or touch pad, for example,
would reduce the mouse area to less than 0.01 m
2
. Unless
the worker uses the numeric keypad, a shorter keyboard might
be substituted. By holding a document on an incline, a stand
or holder can reduce its footprint. With the many choices of
computer input devices and work stations that are now
available, the feasibility of these adaptations of course depends
on job demands and individual capacities. Additional anthro-
pometric guidelines for design of computer work stations have
been published by the Human Factors and Ergonomics
Society.
25
1
0.8
0.6
0.4
0.2
0
0.2
0.4
0.6
0.8
0 0.2 0.4 0.8 0.6 1 1.2
5% percentile female stature
elbow height = shoulder height = 1.23m
C
1
0.8
0.6
0.4
0.2
0
0.2
0.4
0.6
0.8
0 0.2 0.4 0.8 0.6 1 1.2
5% percentile female stature
elbow height = 0.99m
D
95% percentile male stature
elbow height = shoulder height = 1.54m
95% percentile male stature
elbow height = 1.23m
1.4
1.2
1
0.8
0 0.4 0.8 0.2 0.6 1 1.2
A
1.4
1.2
1
0.8
0 0.4 0.8 0.2 0.6 1 1.2
B
1.2
1
0.8
0.6
0.4
0.2
0
0.2
0.4
0.6
0.8
1
1.2
0 0.2 0.4 0.8 0.6 1 1.2
E
1.2
1
0.8
0.6
0.4
0.2
0
0.2
0.4
0.6
0.8
1
1.2
0 0.2 0.4 0.8 0.6 1 1.2
F
Figure 5e.8 Reach envelopes computed
according to National Health Survey Data of
stature and relative link length data reported
by Drillis and Continni.
16
(A and B) Side views
of someone with 5% female stature and average
body proportions with an arm outstretched at
shoulder height and the shoulder constrained to
60 degrees (Re. horizontal). Restricting
shoulder flexion to 60 degrees reduces reach
distance by 21% from 0.66 to 0.52 m and
elbow height from 1.23 to 0.99 m. (C and D)
Top views of the elbow height reach envelopes
for the 5 percentile females with and without
shoulder constraints. (E and F) Top views of
the elbow height reach envelopes for the
95 percentile males with and without shoulder
constraint. For the large male, restricting
shoulder flexion reduces reach distance by
22% from 0.83 to 0.65 m and reduces elbow
height from 1.54 to 1.23 m.
The above calculations were based on standard percentiles.
Similar calculations can be performed based on link length
estimates for an individual by using the link length fractions
reported by Drillis and Contini
16
and displayed in Table 5e.1a or
those reported by Dempster
15
and others.
13,29
Minimizing the reach distance helps to minimize the load
on the shoulder. Work that requires continuous visual feedback
may result in prolonged neck flexion, however, requiring a trade-
off between loads on the shoulder and neck. The solution
depends on the task. Most experienced keyboard users, for
example, can work without watching their hands; however,
documents laid flat on the work surface require the worker to
look down. In many cases this problem can be solved with a
document holder. It is not uncommon, particularly in medical
billing, for the source documents to contain many pages that are
bound together and may require a custom holder. In some cases,
like fine assembly and dental work, it is necessary to bring
the work in line with the eyes, often by providing arm and body
supports.
The traditional assembly line presents some special design
challenges because it is often in continuous motion and difficult
to make work stations individually adjustable (Fig. 5e.9a). Also,
the worker often must reach over a structure along the sides
of assembly line. Space is required not only for the line itself,
but also for parts containers and tools. Parts may be stacked in
front of, beside, or behind the worker, whereas tools may be sus-
pended overhead or mounted or laid along the side of the line.
There have been many improvements in manufacturing meth-
ods over the last 30 years that help to address these issues. Lean
manufacturing discourages large inventories of parts that fill up
the work space and increase reach requirements (Fig. 5e.9b).
There is increasing emphasis on kitting of parts so that only
those needed for a specific assembly are delivered to the work
site at the time required. In addition to reducing inventory costs,
these methods also reduce reaching.
Tool weight control
Loads can also be reduced by decreasing the weight of work
objects by using lighter tools, for example. Armstrong et al
2
found that workers consistently rated hand tools weighing more
than 18 N as too heavy. The weight of a work object may
otherwise be an asset; for example, the weight of a power tool for
driving threaded fasteners or for sanding or buffing may reduce
the force required. Of course, this is true only with horizontal
surfaces, when the worker is driving threaded fasteners down or
sanding or polishing the top, as opposed to underneath, where
tool weight would be a liability. Tools that work well in one
situation may not work well in another. Adaptation development
requires a thorough job analysis.
Mechanical assists
A mechanical assist can be defined as any mechanical device that
helps to reduce the task demands on the worker. In this context
we are concerned with devices that reduce the load moments
about the elbow, shoulder, and neck. A mechanical assist may
range from a complex robotic device capable of supporting high
forces with low-force guidance to a simple work surface that
relieves the worker of the need to support an object in use. Some
examples of mechanical assists include the following:
Lifts raise or lower materials to reduce bending and reaching and
support work objects while they are in use.
A
B
Figure 5e.9 (A) A traditional continuously moving assembly line. Parts are stored in front, beside, and behind the worker. (B) A modern lean
line in which the parts for each operation are supplied in kits that follow the assembly on the line. The line stops until the work is complete.
Turntables rotate materials and work objects to reduce reaching.
Tool balancers support tools against gravity.
Articulating arms may be neutrally balanced to support tools
and resist reaction forces and may be powered to provide
increased lifting capability for heavy objects.
Carts may be used to support work objects while in use and to
transport them from one work station to another.
Mounting fixtures and brackets hold tools in convenient locations/
orientations when not in use.
Work fixtures and jigs hold work objects, reduce loads otherwise
required to hold or use them, and free one or both hands for
performing useful work.
Work benches support the weight of work objects and should be
adjustable to accommodate various heights of users and tasks.
Tools and power tools ranging from a simple pry bar to a complex
poster tool combined with an articulating arm reduce the
strength required to perform tasks.
Although mechanical assists can greatly reduce physical loads
and task demands, failure to design, select, and install them
properly can result in stressful postures and increased workloads.
Assists must also be easily adjustable to suit each worker and
task. Additional details of these devices are beyond the scope of
this chapter but are readily available on the Internet.
Worker fitness and weight
National health survey data show that the level of obesity in our
society is growing rapidly.
12
Although fitness and weight training
are the concerns of health care providers, job designers need to
understand their effects on work capacities and ability to meet job
demands (Fig. 5e.1). Workers with low fitness levels exert less force
for a given amount of time. Load moments on the shoulder of
heavy people tend to be higher than those for a person with a low
body weight because their arms are heavier (Table 5e.1c). Large
body masses encroach on the work space close to the body, which
is the ideal location for many work objects. A large body mass also
may require a worker to reach farther and to produce greater
shoulder moments than a small body mass. The treating physician
or therapist should be consulted regarding how the work space
should be adapted for a worker with a very large body mass.
Body supports
Body supports such as arm rests are widely used to counteract
gravity forces on the body.
1,5,18,19
In the absences of arm rests,
workers often use the edge of the work bench, desk, or keyboard
or the work object itself, padded with pillows, foam pads, pack-
ing materials, and duct tape. Although improvised arm rests
may look crude, they are often more effective than those pro-
vided with a chair or by the employer because their position is
just right for specific workers and tasks. Although chair arm rests
may be fine when the arms are relaxed at the sides, they may
not be close when the work task is performed, or worse they may
actually obstruct a workers arm motions. It is increasingly com-
mon, however, to find chair arm rests with vertical and lateral
adjustability. Arm rests in motor vehicles are frequently
adjustable, folding down to support the arm for highway driving
and up and out of the way for city driving.
Forearm rests can also be mounted on articulating arms
that adjust vertically and move freely in a horizontal plane.
Articulating forearm rests are well suited for keyboard- and
mouse-intensive jobs and for some bench assembly work.
Forearm rests may be fashioned also from slings suspended
from balancers overhead that enable the worker to move in three
dimensions while reducing loads on the shoulder. As with bal-
ancers used for power tools, placement and force adjustments for
each worker and task are very important.
Evaluation of adaptations
It is important that workplace adaptations be evaluated to ascer-
tain their effectiveness. A well-intended adaptation may increase
rather than reduce work demands because it was ill-conceived or
improperly installed or adjusted. As a minimum, evaluations
should include inspection of the job. A more formal assessment
may require time- and event-based analyses of work postures and
forces. Worker feedback in the form of perceived exertion from
one or more users also may be used to evaluate the intervention.
As a practical matter, there is very seldom sufficient control or
statistical power to show a significant reduction in chronic soft
tissue complaints and impairments, but most employers continue
to monitor health records for possible changes.
SUMMARY
Resulting from job demands that exceed an individuals
work capabilities, disability can be controlled by reducing these
demands through workplace adaptations or by increasing work-
ers capabilities through medical treatment and physical therapy.
Determining disability and designing adaptations require under-
standing of the exposure-response relationship, which provides
a framework for work factors, external workloads, internal tissue
loads, pain, fatigue, and MSDs. Many examples of mechanical
assists and body supports can be found by searching the Internet.
Population and individual anthropometric data can be used to
specify workplace layouts, equipment, tools, and procedures
that help to reduce job demands and disability. Workplace adap-
tations should be evaluated to verify that they have achieved
their intended effect.
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C HA P T E R
Wrist and Hand
6
C HA P T E R
6a
Epidemiology of Wrist
and Hand Disorders
David Rempel and Laura Punnett
This chapter summarizes the findings of epidemiologic studies
that address workplace and individual factors associated with
hand and wrist musculoskeletal disorders (MSDs). From an
epidemiologic point of view, this topic is challenging because
although many specific hand and wrist disorders such as carpal
tunnel syndrome (CTS) and hand-arm vibration syndrome
are recognized, no criteria for case definitions are universally
accepted. More data are available for CTS than for other hand
and wrist disorders because of its relatively well-defined pathology
and available diagnostic methods such as nerve conduction
velocity testing.
79
These disorders are not new; epidemics and clinical case
series of work-related hand and wrist tendinitis were reported
throughout the 1800s and early 1900s.
17,92
As summarized by a
review by a National Academy of Sciences panel,
65
many cross-
sectional studies and more recent prospective studies consistently
identify certain key risk factors at the same time that they point
to the multifactorial nature of work-related hand and wrist dis-
orders. The etiology of these disorders includes both biomechani-
cal and work organizational factors, along with reporting and
clinical progression that are likely affected by the workers per-
ception of the work environment and by medical management.
A conceptual model of this complicated relationship, adapted
from Armstrong et al
4
and presented in Figure 6a.1, is based on
epidemiologic studies and pathophysiologic mechanisms clari-
fied in laboratory studies. Health care providers can apply this
information and limit workplace exposures to risk factors both
to reduce the overall incidence of hand, wrist, and other mus-
culoskeletal disorders (primary prevention) and to prevent loss of
function in patients (secondary and tertiary prevention) in whom
such disorders have occurred.
FREQUENCY, RATES, AND COSTS
National incidence rates of work-related hand and wrist disorders
in the United States are not easy to assess because of the difficulty
in attributing causation and the sparse data on background inci-
dence and prevalence. Annual incidence rates of all work-related
repeated-motion disorders reported by U.S. private employers
to the Bureau of Labor Statistics are shown for 1980 to 2000 in
Figure 6a.2. Approximately 55% were hand or wrist disorders,
a percentage also reported in industrial studies
60
and in studies
from other countries.
46
The dramatic rise after 1983 may be
partially explained by early industry under-reporting on the
Occupational Safety and Health Administration (OSHA)
200 log, a factor partially rectified in the early 1980s after OSHA
levied large fines against some meat processing and automobile
manufacturers for under-reporting. A similar calendar trend in
work-related hand/forearm problems has been observed in other
countries such as Finland,
46
Australia,
7
and Japan.
70
Rates of hand and wrist symptoms and associated disability
among working adults were assessed by a 1988 national interview
survey of 44,000 randomly selected U.S. adults (National Health
Interview Survey).
71
Of those who had worked any time in
the past 12 months, 22% reported some finger, hand, or wrist
discomfort that fit the category pain, burning, stiffness, numb-
ness, or tingling for 1 or more days in the past 12 months. Only
one fourth were due to an acute injury such as a cut, sprain,
or broken bone. Nine percent reported having prolonged hand
discomfort, that is, discomfort of 20 or more days during the last
12 months or 7 or more consecutive days that was not due to
an acute injury. Of those with prolonged hand discomfort, 6%
changed work activities and 5% changed jobs because of the
hand discomfort. From the same data set it was estimated that in
1988 alone there were 520,000 cases of work-related hand and
wrist disorders (CTS and tendon syndromes) in the United States.
89
Administrative records (e.g., workers compensation) are
frequently used to estimate incidence rates, but the data are
extremely problematic to interpret because of varying decision
rules that may have no clinical value in defining a case. For
example, Fine et al
26
evaluated multiple records for the same
time period at two U.S. automobile plants. Within each facility
the magnitude of the incidence rates of hand and arm disorders
varied dramatically between data sources: The rates were 10 times
higher in the workers compensation records than in the OSHA
200 log and 10 times higher in the plant medical records than in
the compensation data. Nevertheless, the relative ranking of the
departments within each plant was similar, regardless of which
data source was used.
The incidence of work-related CTS, impact of work disability,
and factors predicting disability have been assessed on a large scale
in Washington State. A review of 7926 workers compensation
claims for CTS from 1984 to 1988 yielded an industry-wide
Individual factors
Size
Capacity
Behavior
Repair
Work-related factors
Work organization
Repetition
Force
Posture
Internal load (dose)
Discomfort
Pain
Disorder
Disability
Figure 6a.1 A possible model of the relationship between exposure
to work, worker attributes, and development of chronic musculoskeletal
disorders of the hands and wrist. Internal loads and individual capacity
result in a reversible cascading series of events ranging from minor
mechanical or biologic disturbances to tissue damage and disability.
(Modified from Armstrong TJ, Buckle P, Fine LJ, et al: Scand J Work
Environ Health 19:73-84, 1993.)
incidence rate of CTS claims of 1.74 per 1000 full-time employees.
27
Rates up to 20 cases per 1000 full-time employees were observed
in shellfish, fish, and other meat-packing industries. Industries
with the highest rates of occupational CTS are presented in
Figure 6a.3. The ranking of these rates also shows a high
correspondence with the occupations in Finland having the
highest rates of hand, wrist, and forearm disorders, despite some
geographic differences in industry.
Disability burden was quantified as years of productivity
lost, addressing time lost from work for incident compensa-
tion claims in 1986.
30
Upper extremity strains were the third
highest cause of years of productivity lost, after sprains of the
back/neck and lower extremity, representing 1.8 years lost per
thousand workers per year. CTS had a lower incidence rate but
caused more lost time per case, accounting for 0.5 years lost per
1000 worker-years. Approximately 40% of all the Washington
State workers with CTS went on to surgical treatment.
1
Of these,
the mean duration of lost time was 4 months. The length of
time lost from work was not associated with demographic factors
(age, gender, wage) or case severity as assessed by clinical staging
or nerve conduction values. Most (67%) returned to the same
job, 15% found a different job, and 3 years after surgery 18%
Chapter 6a Epidemiology of wrist and hand disorders 212
I
n
c
i
d
e
n
c
e

r
a
t
e

(
p
e
r

1
0
0
0

p
e
r
s
o
n
-
y
e
a
r
s
)
0.0
1624 2534 3544 4554 5564 >65
0.5
1.0
1.5
2.0
2.5
3.0
Age
Figure 6a.2 Incidence rates (per 1000 full-time employees) of repeated-motion disorders for all U.S. private-sector workers from 1980 to 2000.
The lower curve is the incidence for industries with primarily office work (finance, insurance, and real estate). Approximately 55% are hand/wrist
disorders. (From Bureau of Labor Statistics, 1980-2000.)
Figure 6a.3 Population age-specific incidence rates of carpal tunnel syndrome for Rochester, Minnesota, from 1961 to 1980 () (n = 1016)
75
as compared with work-related incidence rates for the Washington State workers compensation system from 1984 to 1988 (...) (n = 7926).
28
had not returned to work. Workers from jobs with elevated rates
of CTS or those involving repetitive hand activity were less likely
to return to the same job. A return to repetitive or physically
demanding work is a predictor of poor long-term outcome after
surgery.
2,58
Few data are available to assess the long-term financial and
functional impact on patients and society, but best estimates by
the National Academy of Sciences panel place the average direct
cost per workers compensation case at over $8000, with total
cost estimates for all MSDs as high as $45 to $54 billion per year,
around 0.8% of the nations gross domestic product.
65
A popu-
lation survey in Connecticut indicated that only about one in
five persons with medical treatment for work-related MSDs
was reimbursed by compensation and that they had substantial
other social and economic costs, ranging from loss of function to
decreased job advancement to losing a car or home for financial
reasons.
62
DISORDER TYPES AND THEIR
NATURAL HISTORY
Figure 6a.3 lists some hand and wrist disorders identified in
occupational epidemiologic studies. Nonspecific hand/wrist pain
is the most common problem, followed by tendinitis, ganglion
cysts, and CTS.
38,53,60,86
In their early stages, these disorders may
be manifested by nonspecific symptoms without signs or labora-
tory findings. It is important to remember that symptoms in the
hand may be due to nerve or vascular lesions further up the arm.
When measured in high-risk workplaces, rates of nonspecific
symptoms, tendinitis, and CTS appeared to track each other;
that is, specific disorders usually do not occur in isolation. For
example, in a pork processing plant, the rank order of hand and
wrist problems as a percentage of all morbidity was nonspecific
hand/wrist pain, 39%; CTS, 26%; trigger finger, 23%; trigger
thumb, 17%; and de Quervain tenosynovitis, 17%.
61
Among packers in a bread factory, whose work involved repeti-
tive and forceful gripping, approximately one half had wrist/hand
tenosynovitis (compared with 14% among retail shop assistants).
53
The most common disorder of the hand or wrist was thumb
tenosynovitis, followed by finger/wrist extensor tenosynovitis.
CTS was diagnosed in four packers and in no control subjects.
Similar ratios of disorders have been observed in manufacturing
workers,
6,60,86
food processors,
47,53
and computer operators.
9,38
For the purposes of this chapter, tendinitis includes hand,
wrist, and distal forearm tendinitis or tenosynovitis and trigger
finger. Tendinitis occurs at discrete locations, the most common
site being the first extensor compartment (de Quervain disease),
followed by the five other pulley sites on the extensor side of the
hand and three on the flexor side. The diagnosis is based on the
history, symptom location, and palpation and provocative
maneuvers on physical examination.
34
No association of tendini-
tis with age has been found, but a bimodal curve with seniority
has been described; work-related tendinitis was higher among
workers with less than 3 years of employment, for example,
60
suggesting that performance of unaccustomed tasks is a risk fac-
tor and/or that affected workers are less likely to remain in the job.
In cross-sectional workplace studies, the prevalence of ganglion
cysts, as assessed by physical examination, is 2% to 3%.
9,38,60
Whether these rates are higher among those performing repeti-
tive hand activity versus those performing tasks with low repeti-
tiveness is unknown.
In the absence of universally accepted diagnostic criteria for
CTS, some consider just an abnormal nerve conduction study
a gold standard.
39,45,63
Relying exclusively on nerve conduction
studies can lead to very high prevalences, however, such as
28%
63
and 19%
8
in low-risk working populations. The usual signs
of CTS have relatively poor sensitivities and specificities
28,39,45
;
only in the late stages of the disease or in the elderly are weak-
ness and thenar atrophy noticeable features, and in approxi-
mately 25% of cases, CTS is accompanied by other disorders of
the hand or wrist.
72
Although consensus criteria using symptom
history and nerve conduction study findings have been pro-
posed,
79
the combination of a positive nerve conduction velocity
test and symptoms consistent with CTS represents a preferable
case definition.
Few studies have evaluated how osteoarthritis of the hand
and wrist relates to work.
35,99
Hadler et al
35
assessed the hands
of 67 workers at a textile plant in Virginia. Significant differences
in finger and wrist-joint range of motion, joint swelling, and
radiograph patterns of degenerative joint disease were observed
between three different hand-intensive jobs; the observed dif-
ferences were reported to match the pattern of hand usage.
Hand-arm vibration syndrome, or vibration white finger
disease, occurs in occupations involving many years of exposure
to vibrating hand tools.
66
This disorder of the small vessels and
nerves in the fingers and hands is manifested as localized blanch-
ing at the fingertips with numbness on exposure to cold or vibra-
tion. The symptoms are largely self-limited if vibration exposure
is eliminated at an early stage,
20,31
but with continuing exposure
the condition becomes irreversible.
Hypothenar hammer syndrome, or occlusion of the superfi-
cial palmar branch of the ulnar artery, has been associated in
clinical series and case-control studies with habitually using the
hand for hammering
52,69
and with exposure to vibrating hand
tools.
44
The mean length of exposure before seeking medical
attention was 20 to 30 years. Small case-control studies or clini-
cal series have described factors associated with less common
disorders such as gamekeepers thumb,
14,68
digital neuritis, ulnar
neuropathy at the wrist,
86
and Kienbck disease.
32
INDIVIDUAL FACTORS
In general population studies and clinical case series, the average
age of patients with CTS is approximately 55 years.
10,72,88,100
In contrast, the mean age for occupational cases, based on the
Washington State workers compensation study, is 37.5 years.
27
Furthermore, as displayed in Figure 6a.3, the incidence increases
with age in the general population but does not appear to do
so in the occupational cohort. Only 3% of the variability in
median nerve latency in a cross-sectional study of an industrial
cohort is explained by age.
63
In another prospective study, age
was not a predictor for incidence of CTS or for wrist tendonitis
in a mixed occupational cohort
51
or of tendon-related disorders
of the hand and forearm among computer users.
34
Similarly, gender appears to play a greater role in population-
based studies of CTS than in industrial studies. In regional
Chapter 6a Individual Factors 213
population studies and clinical series, the incidence of CTS is higher
in females than in males by a factor of 2.2:1 to 3.7:1,
10,72,88,100
whereas in workplace studies, when employees perform similar
hand activities, the ratio is much closer to unity at 1.2:1.
27,34,63,86
CTS can be a sequela (usually self-limiting) of pregnancy
21
;
however, the role of other female reproductive factors such as
oophorectomy, hysterectomy,
11,15,18,77
or the use of oral contra-
ceptives
82
is less certain. The overall implications are that when
hand activities are taken into account, the differences between
working men and women are not particularly prominent, and
hormonal influences likely account for relatively little morbidity
when ergonomic exposures are high.
76
Other individual factors with strong associations to CTS
are diabetes mellitus,
72,88,100
rheumatoid arthritis,
72,88,100
and obe-
sity.
18,23,63,94,97
For other factors, including thyroid disorders,
38,72
vitamin B
6
deficiency,
3,22,59
wrist size and shape,
5,12,33,43
and general
deconditioning,
63
the associations are based on single studies or
the studies present conflicting results. Nonspecific distal symptoms
have also been associated with systemic disease, obesity, smoking,
and other nonoccupational factors.
51,73,75
WORK-RELATED FACTORS
Figure 6a.3 summarizes the characteristics of work that have
been associated with elevated rates of hand and wrist symptoms
and with specific disorders like CTS and tendinitis. The number
of prospective studies has increased substantially in recent years,
and the risk factors identified tend to be quite consistent with
those of older cross-sectional studies of the same endpoints.
95
Tables 6a.1 and 6a.2 summarize selected studies of wrist and
hand tendinitis and CTS that included a control group.
Hand/wrist pain and disorders have been associated with
repetitive hand and finger motions characterized by a variety of
metrics. Prevalences are generally high in manual-intensive
occupations such as data-entry work, postal sorting, cleaning,
industrial inspection, and packaging.
65
In a study relying exclu-
sively on nerve conduction measurements, median nerve slow-
ing occurred at a higher rate among assembly line workers than
among administrative control subjects.
64
Assembly line workers
appeared to have more repetitive tasks than the control group.
Similar results were obtained in comparisons of garment workers
performing repetitive hand tasks with hospital employees not
using computer keyboards
77
and in bread packers compared with
retail shop attendants.
53
A number of other cross-sectional and
prospective studies have similarly observed the importance
of high hand pace, short cycle time, little variation in tasks, and
lack of rest breaks for risk of CTS,
8,16,50,80,98
tendinitis,
47
and hand
pain or combined disorders.
25,49
This range of metrics illustrates
the varied ways that repetitive motion may be operationalized
in addition to high velocity or acceleration of the wrist or rate
of repetition of postural stress.
57
The force applied to a tool or materials during repeated
or sustained gripping is also a predictor of the risk for tendinitis,
CTS, and other distal extremity disorders. For example, in a
study of the textile industry, the risk of hand and wrist tendinitis
was 3.9 times higher among packaging and folding workers
than among knitting workers, who performed work that was
Table 6a.1 Selected controlled epidemiologic studies evaluating the association between work and wrist,
hand, or distal forearm tendinitis*
Rate in Rate in
Authors Exposed population Control population exposed (%) control (%)
Kuorinka et al, 1979 90 scissors makers 133 shop attendants 18 14
Luopajarvi et al, 1979
53
152 bread packaging 133 shop attendants 53
14
Silverstein et al, 1986
86||
Industrial Industrial
143 low force/high rep 136 low force/low rep 3? 1.5
153 high force/low rep 136 low force/low rep 4? 1.5
142 high force/high rep 136 low force/low rep 20
1.5
McCormack et al, 1990
60
Manufacturing Manufacturing
369 packers/folders 352 knitting workers 3.3
0.9
562 sewers 352 knitting workers 4.4
0.9
296 boarding workers 352 knitting workers 6.4
0.9
Kurppa et al, 1991
47
102 meat cutters 141 office workers 12.5? 0.9
107 sausage makers 197 office workers 16.3
0.7
118 packers 197 office workers 25.3
0.7
Latko et al, 1999
49
352 manufacturing workers (high/low rep) OR = 3.23
*Case criteria are based on history and physical examination.
All exposed and control subjects are female.
Significant difference from control.
Adjusted for age, sex, and plant.

||
Analysis includes other disorders, although tendinitis was most common.
Cohort study with a 31-month follow-up.

OR, odds ratio.
much less physically demanding. In a study by Moore and
Garg
61
at a pork processing plant, in the jobs that involved high
grip force or long grip durations such as Wizard knife operator,
snipper, feeder, scaler, bagger, packer, hanger, and stuffer, almost
every employee was affected. Others observed a similar relation-
ship with work involving sustained or high force grip in grinders,
64
meatpackers and butchers,
23,47
and other industrial workers.
51,92,96
A comprehensive cross-sectional study of the combined fac-
tors of repetition and force was conducted among 574 industrial
workers by Silverstein et al.
86,87
Disorders were assessed by phys-
ical examination and history and were primarily tendinitis fol-
lowed by CTS, Guyon tunnel syndrome, and digital neuritis.
Subjects were classified into four exposure groups based on force
and repetition. The high-force work involved a grip force
averaging more than 4 kg of force, whereas low-force work
involved less than 1 kg of grip force. The high-repetition work
involved a repetitive task in which either the cycle time was less
than 30 seconds (greater than 900 times in a work day) or more
than 50% of the cycle time was spent performing the same kind
of fundamental hand movements. After adjusting for plant, age,
gender, and years on the job, the high-risk groups were compared
with the low-risk group. The odds ratio of all hand/wrist disor-
ders for high force alone was 5.2 and that for high repetition
alone was 3.3; this increased to 29 for jobs that required both
high force and high repetition. The identical analysis of just
CTS revealed an odds ratio of 1.8 for force, 2.7 for repetition,
and 14 for the combined high-force high-repetition group.
Years of exposure to both repetitive wrist movement and
heavy load on the wrist were strongly associated with CTS.
83
Estimates of the CTS cases among workers who perform repeti-
tive or forceful hand activity that can be attributed to work range
from 50% to 90%.
36,91
Other investigations similarly highlighted
the combined effects of repetition, force, postural load, and
other physical stressors.
37, 77, 80
The importance of addressing all
such exposures simultaneously in workplace interventions is
further demonstrated by the effect of multifaceted ergonomic
interventions in reducing upper extremity morbidity.
13,25,67
Work involving increased wrist deviation from a neutral
posture in either the extension/flexion or ulnar/radial direction
has been associated with CTS and other hand and wrist prob-
lems.
40,92,93
de Krom et al
18
conducted a case-control study of
156 subjects with CTS versus 473 control subjects randomly
sampled from the hospital and population registers in a region
of the Netherlands. After adjustment for age and sex, a dose-
response relationship was observed for increasing hours of work
with the wrist in extension or flexion. No risk was observed for
increasing hours performing a pinch grasp or typing, although
methodologic limitations may have obscured such associations.
Some studies of computer operators have linked awkward wrist
postures to severity of hand symptoms,
24
risk of tendinitis or
CTS,
84
and arm and hand discomfort.
19,41,83
In a large population
sample, both CTS and distal tendonitis were associated with
repetitive occupational bending and twisting of the hands and
wrists.
89,90
Wrist angles measured by electrogoniometry were
strongly linked with wrist disorders in a range of service and
manufacturing occupations; forceful exertions and repetitiveness
were also risk factors, although they were correlated with each
other too strongly to distinguish their effects.
55
Prolonged exposure to vibrating hand tools such as chain
saws has been linked in prospective studies to hand-arm vibra-
tion syndrome.
20,31
The risks are primarily vibration acceleration,
amplitude, and frequency; hand coupling to tool; hours per day
of exposure; and years of exposure. Based on existing studies,
however, no clear vibration acceleration/frequency/duration
threshold has been found that would protect most workers.
Medical surveillance is therefore recommended to identify
Chapter 6a Work-Related Factors 215
Table 6a.2 Selected controlled epidemiologic studies evaluating the association between work and carpal
tunnel syndrome*
Rate in Rate in
Authors Exposed population Control population Criteria exposed (%) control (%)
Silverstein et al, 1987
87
Industrial Industrial History and physical 5.1
0.6
High force/high rep Low force/low rep examination
Nathan, 1988
64||
22 keyboard operators 147 admin/clerical Electrodiagnostic 27 28
164 assembly line 147 admin/clerical Electrodiagnostic 47 28
115 general plant 147 admin/clerical Electrodiagnostic 38 28
23 grinders 147 admin/clerical Electrodiagnostic 61
28
Barnhart, 1991
8
106 ski manufacturing 67 ski manufacturing Electrodiagnosis and 15.4
3.1
repetitive jobs nonrepetitive jobs signs
Roquelaure et al, 1997
80
65 factory workers/65 case Symptoms, signs, OR = 9.0 (2.4-33.4)
controls electrodiagnosis, for force and OR = 8.8
surgery (1.8-44.4) for repetition
*Diagnoses are based on history and physical examination or nerve conduction study.
Controlled for age, gender, and years on job.
Significantly different from control group.
Controlled for age and gender.

||
Low participation rate and limited exposure assessment.
OR, odds ratio.
cases early while the disease can still be reversed.
66
Nonetheless,
both the American National Standards Institute and the
International Standards Organization have promulgated guide-
lines limiting the duration of exposure as a function of accelera-
tion and frequency. The use of vibrating hand tools may also
increase the risk of CTS,
15,81,85,98
either by direct nerve injury
or by indirectly increasing applied grip force through a reflex
pathway.
78
Prolonged or high-load localized mechanical stress
over tendons or nerves from tools or from resting the hand on
hard objects has been associated with tendinitis
93
and nerve
entrapment
40,72
in case studies.
The average total hours per day that a task is repeated or
sustained has been a factor in predicting hand problems.
54,56
For example, an increase in hours of computer use has consis-
tently been a predictor of increased symptom prevalence.
9,24,26,41,74
In prospective studies of computer users, increasing hours of
keyboard and mouse use predicted increased incidence of hand/
wrist pain and tendonitis, especially above 20 hours per week.
34,42
In cross-sectional studies, work organizational factors (e.g.,
work structure, decision control, workload, deadline work,
supervision) and psychosocial factors (e.g., job satisfaction, social
support, relationship with supervisor) appear to have some influ-
ence on hand and wrist symptoms. Work organizational factors
represent upstream determinants of both physical motion patterns
and subjective psychosocial work experiences. For example, just-
in-time production systems increase both the work pace
48
and
the risk of CTS.
50
In an automotive manufacturing plant, improved
work station design was negatively offset by a change to assem-
bly line production with very short-cycle, monotonous, robot-
ized jobs.
29
Among banking employees, longitudinal changes in
work scheduling and rest break policies were shown to predict
changes in medical morbidity.
25
Among newspaper reporters and
editors, psychosocial factors modified the expected relationship
between work station design and hand and wrist symptoms.
Symptom intensity increased as keyboard height increased
among those with low decision latitude but not among those
with high decision latitude.
24
In another study of newspaper
employees, the risk of hand and wrist symptoms was increased
among those with increasing hours of deadline work and less sup-
port from the immediate supervisor.
9
Among directory assistance
operators at a telephone company, high information-processing
demands were associated with an elevated rate of hand and wrist
disorders.
38
On the other hand, in an industrial setting,
Silverstein et al
86
observed no association with job satisfaction.
Because these problems may develop in the workplace after and
as a consequence of employees symptoms and unsuccessful
efforts to obtain job modifications or other accommodation,
psychosocial factors are the most difficult to interpret in cross-
sectional studies. Overlapping measurement approaches may also
obscure the relationships among work organization, physical,
and psychosocial factors.
SUMMARY
Although variability exists between industries, hand and wrist
disorders account for many work-related upper extremity MSDs.
These disorders are costly to the worker, employer, and workers
compensation system; however, a full accounting of their finan-
cial impact has yet to be done. Hand and wrist problems may
present in any number of ways, from the most common pres-
entation of nonspecific hand symptoms to discrete entities such
as hand-arm vibration syndrome or de Quervain tenosynovitis.
The rates of specific disorders correspond to high symptom rates
in a work population.
Studies point to a multifactorial relationship between
work and these disorders. Some disorders such as tendinitis and
CTS are clearly associated with repetitive and forceful hand use,
postural stress, and vibration. For other disorders such as gan-
glion cysts and osteoarthritis, the relationship to work has not
been well studied. Symptom severity and disorder ratesor
at least their reportingappear to be influenced by work organi-
zational factors such as decision latitude and cognitive demands.
In population-based studies and clinical case series, CTS in
particular has been linked to individual factors. However, in
workplace studies when workplace exposure is high and quanti-
fied, individual factors play a limited role relative to workplace
factors.
5,15,24,38,41,87
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C HA P T E R
6b
Biomechanics of the
Wrist and Hand
Rita M. Patterson and Kai-Nan An
The human hand is a relatively mobile three-dimensional structure
capable of conforming to the shape of manipulated objects. The
biomechanical structure of the hand can be considered a linkage
system of intercalated bony segments balanced by muscle and
tendon forces and joint constraints. This chapter reviews some of
the unique qualities that affect the biomechanics of the hand and
wrist: normal skeletal and soft tissue anatomy, joint constraint
and stability, range of joint motion and strength, and more basic
biomechanical considerations of muscle-tendon function.
SKELETAL AND LIGAMENTOUS
ANATOMY/JOINT CONSTRAINT
Joint constraint and stability are provided by the joint articular
surfaces, the capsuloligamentous structures, and the musculo-
tendinous units. Primary joint stability is related to balance of
the muscle and tendon forces to an externally applied force, with
the capsuloligamentous structures appearing to stabilize initially
against instantaneous loading and to provide secondary main-
tenance of joint stability. The collateral ligaments of all the hand
joints and the intercarpal ligaments in the wrist are important
soft tissues for joint constraint.
The locations and orientations of the ligament lines of action
determine their characteristics in resisting loads on the joint. For
example, the radial collateral ligament and the ulnar collateral
ligament are the primary ligaments of the metacarpophalangeal
joint. Originating from the radial-dorsal aspect of the metacarpal
head with insertion into the radial-volar aspect of the proximal
phalanx, the radial collateral ligament is the primary ligament
resisting ulnar deviation and pronation of the proximal phalanx
at the metacarpophalangeal joint. The ulnar collateral ligament,
on the other hand, is the primary constraint in resisting radial
deviation and supination of the proximal phalanx.
The relative contribution of each of the ligaments in resisting
joint displacement has been studied by sequential sectioning or
removal of the individual ligaments (Fig. 6b.1). The reduction of
the load after removal of each ligamentous structure represents
the contribution of that ligament.
Anatomic studies performed on the carpal bones and the
ligaments of the wrist in particular have identified several mor-
phologic differences associated with degenerative changes and with
specific kinematic (motion) patterns. Viegas and colleagues
14
iden-
tified two different lunate shapes. Type II has a facet that articu-
lates with the hamate and has been associated with increased
arthritis in its proximal pole. Type I has no facet.
Most wrist ligaments are considered true intracapsular ligaments
and tend to be oriented obliquely, from the periphery of the
wrist toward the midline, from a proximal to distal direction.
The volar ligaments are well established as the primary stabilizers
of the wrist joint. Studies investigated the anatomy and mechan-
ical strength of the dorsal ligaments of the wrist. Together the
dorsal intercarpal (DIC), dorsal radiocarpal, and dorsal scapho-
lunate (SL) interosseous ligaments create a lateral V that deliv-
ers indirect dorsal stability between the scaphoid and the radius
while still allowing a threefold change in distance between the
radius and the scaphoid dorsal groove. This unique design allows
dorsal stability of the scaphoid throughout the range of motion
of the wrist that would require changes in the linear dimension
of a dorsal radioscaphoid ligament far greater than any fixed
ligament could accommodate (Fig. 6b.2). The combined mechan-
ical properties of the DIC, dorsal SL interosseous, and dorsal
radiocarpal ligaments together function to maintain scaphoid
stability and alignment while allowing for carpal mobility.
18
Three distinct ligaments around the scaphoid trapezium
and trapezoid (STT) joint have also been identified. The STT
ligaments extend distally (scaphoid trapezial ligament) and
ulnarly (scaphocapitate and scaphotrapezium ligaments) to form
a V. The plane of the V-shaped STT ligament is essentially par-
allel to that of the trapezium-trapezoid articulation and corre-
sponding interfacet ridge on the joint surface of the distal pole
of the scaphoid. This ridge runs radiodorsal to ulnopalmar, a
45-degree angle from the sagittal plane
13
(Fig. 6b.3).
MOTION
The fingers and thumb consist of phalanges articulated at the
interphalangeal joints. Within the physiologic range of motion,
the interphalangeal joints can be considered hinges that allow
flexion/extension. In a normal hand, each interphalangeal joint
has at least 90 degrees of motion. The proximal phalanx articu-
lates with the metacarpal at the metacarpophalangeal joints,
which are usually considered universal joints, allowing not only
flexion/extension but also abduction/adduction. Normally,
the range of flexion/extension is about 90 degrees and that of
abduction/adduction is 20 to 30 degrees.
A composite articulation of eight carpal bones, the wrist joint
connects the digits of the hand to the radius and ulna of the
forearm. The range of wrist motions required to comfortably
perform activities of daily living consists of 60 degrees of exten-
sion, 54 degrees of flexion, 40 degrees of ulnar deviation, and
17 degrees of radial deviation. Most of the hand placement and
range-of-motion tasks can be accomplished with 70% of wrist
motion maximum range. This converts to 40 degrees each of wrist
flexion, wrist extension, and combined radial/ulnar deviation.
Wrist flexion/extension and radial/ulnar deviation has tradi-
tionally been modeled as a fixed center of rotation through the
proximal aspect of the capitate. However, studies have described
the flexion/extension axis of the wrist as moving between the
lunate and capitate. During global wrist motion, the radiolunate
joint contributes more motion in flexion, whereas the lunocapi-
tate joint contributes more motion in extension.
16
Other studies described the kinematics of the lunate and the
differences due to lunate type.
13,18
The kinematics of type I lunate
Chapter 6b Biomechanics of the Wrist and Hand 220
Supination
Pronation
Extended MP joint
a: Intact
b: RCL-P
Sequential
sectioning of
c: RCL-D
d: UCL-P
e: UCL-D
20 10
0.6
0.4
0.2
0.2
0.4
10 20
T
o
r
q
u
e

(
N
-
m
)
a
a
a
a
b
c
a
a
b
c
a
b
c
b
c
d
d
e
Figure 6b.1 Load-displacement curves were obtained by measuring the restraining torques when the metacarpophalangeal joints were displaced
in supination and pronation. Curve a represents the torques with the entire capsule-ligament complex intact. Curves b and c represent the torques
when the palmar and dorsal portions of the radial collateral ligament, respectively, were sectioned, whereas curves d and e represent those when
the palmar and dorsal portions of the ulnar collateral ligament, respectively, were sectioned. The difference in load between each curve for a given
displacement indicates the contribution of that particular sectioned element. For example, the difference in load between curves a and b
represents the contribution of the palmar portion of the radial collateral ligament. N-m, newton-meter. (From An KN, Cooney WP III: Biomechanics,
section II, the hand and wrist. In BF Morrey, ed: Joint replacement arthroplasty. New York, 1991, Churchill Livingstone International, pp. 137-146.)
motion differs from that of type II. The total range of radial/
ulnar translation of type II lunates was greater than that of type
I lunates during radial/ulnar deviation. Compared with that of
type I lunates, extension of type II lunates occurred later during
ulnar deviation, whereas flexion of type II lunates occurred ear-
lier. Describing the kinematics of the STT joint, Moritomo et al
13
found that the trapezium and the trapezoid rotate as a unit with
respect to the scaphoid during either flexion/extension or radial/
ulnar deviation of the wrist.
STRENGTH
The potential strength of various joints in the hand and wrist in
normal subjects has been studied with dynamometers. Normal
pinch strengths ranged from 3 to 10 kg and grasp strengths from
20 to 40 kg. The wrist position and size of the grasped object have
a significant influence on grip strength, which has been studied
extensively as a function of wrist joint position. A self-selected
wrist position of 35 degrees of extension and 7 degrees of ulnar
deviation has been identified as the position in which maximum
grip strength can be generated.
15
For a given size of an object,
grip strength is significantly reduced when the wrist position
deviates from this self-selected position.
Forearm position has been shown also to affect key and
fingertip pinch strength but not three-jaw chuck pinch strength.
The neutral forearm position rendered the highest mean score
and the pronated position the lowest mean score for key and
fingertip pinch strength. Although these effects were consistent,
the statistically significant effects of forearm position were less
than 1 pound of force and may not be clinically relevant.
However, standardized forearm positioning during pinch
strength measurement is still recommended.
17
The strength of the
wrist joint is in the range of 10 to 20 Nm of flexion, 6 to 10 Nm
of extension, 10 to 18 Nm of radial deviation, and 10 to 20 Nm
of ulnar deviation.
TENDON EXCURSION
The ability to control the movement of an individual digit of the
hand depends very much on the anatomic arrangement of the
musculotendinous complex. The magnitude of tendon excur-
sion during joint movement for a given task would be important
also for assessing possible overuse injury caused by cumulative
trauma.
For the finger and thumb, the pulley structures on the palmar
side of the digits restrain bowstringing of the digital flexor
during joint flexion. Alteration of such a pulley system in the
hand disturbs the relationship between tendon excursion and
joint angular displacement, and thus joint function. Parameters
have been defined from the curves of tendon excursion and
joint motion for comparing tendon-pulley joint interactions
under normal and abnormal conditions.
9
The range of move-
ment of the joint produced by a given standardized amount of
excursion is called the effective range of motion. Absolute
tendon excursion is that from full extension to 90 degrees of flex-
ion as measured with the flexor tendon set at its normal length
in the neutral position. Division of the pulley would result
in bowstringing and adding slack to the tendon system, which
would have to be taken up before any joint motion could occur.
This amount of tendon slack is termed bowstring laxity. Subtracted
from absolute tendon excursion, bowstring laxity defines relative
tendon excursion.
The biomechanical functions of the musculotendinous
complex can be understood in terms of the relationship of ten-
don excursion to joint angular displacement. The rate of change
in tendon excursion as the joint rotates is equal to the moment
arm of the associated muscle or tendon for that specific joint
motion.
4
The moment arm defines not only the effectiveness of
the tendon in joint rotation but also its mechanical advantage in
resisting external loads. The larger the moment arm, the higher
the torque and rotation angle generated for the same amount
of muscle force and excursion. A determination of the potential
moment arm contributions of muscles can provide insight into
the balance of forces at a joint for planning tendon transfers or
designing orthotics to help provide mobility or stability while
minimizing loss of function.
Tendon excursion and joint rotation angles of the wrist, for
example, are measured by using an electric potentiometer and an
electromagnetic tracking device, respectively.
1
The instantaneous
moment arms of each tendon are then calculated from the slope
of the curve between the tendon excursion and the joint angular
displacement. Calculated tendon moment arms are found to
be consistent throughout a full range of flexion/extension and
radio/ulnar deviation motion; they correspond closely to the
anatomic location and orientation of the tendons (Fig. 6b.4).
MUSCLE AND JOINT FORCES
The potential force generated by a muscle depends on its size
and architecture. Three anatomic parameters of muscle morpho-
logy have been recognized for their importance in defining its
biomechanical potential
5
: (1) muscle fiber length is related to
the potential range of physiologic excursion of the tendon and
muscle, (2) the physiologic cross-sectional area of a muscle is
proportional to its maximum tension potential, and (3) physi-
cally, the product of the force and distance is work; therefore, the
muscle mass or volume is proportional to its work capacity.
In addition, potential force generation is further regulated by
the velocity of shortening or lengthening of the muscle and,
as is well known, its length at the time of contraction. Usually,
an optimum length can be found for generating maximum con-
tractile force. The arrangement of the muscle fiber architecture
further influences the characteristics of the muscle contraction.
8
It has been demonstrated that parallel muscle fibers produce a
Chapter 6b Muscle and Joint Forces 221
Flexion
Extension
Tq
Sc
Radius
Ulna
Tq
Sc
Radius
Ulna
Figure 6b.2 The lateral V configuration of the dorsal radiocarpal/
dorsal intercarpal construct allows dorsal stability of the scaphoid
along with a threefold change in the distance between the radius and
the dorsal groove of the scaphoid between flexion and extension of the
wrist (arrows).
c
a
FCR
b
Figure 6b.3 The ligaments around the scaphoid trapezium and trapezoid
joint at the palmar aspect of the left wrist. (a) The scaphotrapezial
(S-Tm) ligament; (b) the scaphocapitate (S-C) ligament; (c) the
capitate-trapezium (C-Tm) ligament. FCR, flexor carpi radialis.
length-tension curve with maintained force throughout a wider
range of excursion than do muscles with a shorter fiber pennate
structure, which produce sharply peaked curves. The index of
muscle architecture, defined as the ratio of muscle fiber length to
muscle belly length, has been used to define such characteristics.
The orientation or constraint of muscles or tendons crossing a
joint determines the characteristics of excursion and the moment
arm. In general, the larger the moment arm, the better the
mechanical advantage for the same amount of tendon or muscle
force. On the other hand, the larger the moment arm, the more
tendon excursion expected for the same amount of joint rotation.
The excursion of the tendon eventually affects the muscle length
of contraction and ultimately determines the potential force gen-
eration according to the muscle length-tension characteristics.
The size and shape of the object to be grasped determines
the joint configuration of the thumb and fingers involved in
grasp function. The corresponding moment arms of both the
intrinsic and extrinsic muscles at a particular joint configuration
determine the mechanical advantage, tendon excursion, and
corresponding muscle length. Therefore, as mentioned earlier,
the size and shape of the object are important considerations in
determining the power and strength of the grasp. Furthermore,
the extrinsic muscles of the fingers and thumb originate from the
forearm. Wrist joint motion therefore creates excursion of these
tendons and modifies the muscle contraction characteristics
because of the length-tension relationship. Thus grasp power and
strength are regulated by wrist joint configuration as well.
Because of the relatively smaller moment arms or mechanical
advantage of the muscles and tendons across the joints as
compared with those of externally applied forces at the tip of the
digits, the muscle force required to balance grip or pinch func-
tions is much higher. For example, in the tip and pulp pinch
Figure 6b.4 (Left) Tendon excursion and moment arm of the five wrist motor tendons during flexion/extension motion. (A) Tendon excursion.
The wrist joint was moved from full flexion to full extension passively. (B) Moment arms calculated from A. The flexors and extensors show the
different directions of the moment arm: extensors show the plus, and flexors show the minus. (Right) Tendon excursion and moment arm of the
five wrist motor tendons during radial/ulnar deviation. (A) Tendon excursion. The wrist joint was moved from radial deviation (R.D.) to ulnar
deviation (U.D.) passively. (B) Moment arms calculated from A. The ulnar side tendons show the plus moment, and the radial side tendons show
the minus moment. ERCB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; ECU, extensor carpi ulnaris; FCR, flexor carpi
radialis; FCU, flexor carpi ulnaris. (From Horii E, An KN, Linscheid RL: Excursion of prime wrist tendons. J Hand Surg 18(1):83-90, 1993.)
function, the forces of the flexor profundus and sublimis are
about one to two times the force at the tip of the digits. The asso-
ciated forces in the intrinsic muscles are in the range of 0.5 to
1.5 times the applied forces.
2,3
Accordingly, with such a magnitude
of muscle and tendon forces, the compressive and shear forces
across the finger joints are quite significant (Fig. 6b.5).
FORCE THROUGH WRIST CARPAL JOINT
When the hand is used, the wrist joint encounters a tremendous
amount of force. The distribution of the forces among the
carpal bones has great potential for injury to the associated
bone and soft tissue. Cumulative trauma with compression of
the lunate, for example, has been thought to result in avascu-
lar necrosis of the lunate (Kienbck disease). It has been postu-
lated that excessive and uneven loading is experienced by the
lunate between the lunate fossa of the radius and the com-
pressible triangular fibrocartilage of the ulna. The overall
force transmitted from the proximal row of carpal bones to the
distal radioulnar joint has been examined by numerous investi-
gators. Although the findings have not been in complete agree-
ment and probably depend on the measurement technique,
trends of certain important characteristics have been quite
consistent.
On average, 15% to 20% of axial wrist joint force is trans-
mitted by the distal end of the ulna, and 80% to 85% is trans-
mitted through the radius in the neutral position (Fig. 6b.6A).
7
Chapter 6b Force Through Wrist Carpal Joint 223
CX
4
= 4.9
CX
2
= 2.7
CY
6
= 2.3
A = 1
CZ
6
= 0.2
CX
6
= 3.9
Figure 6b.5 Resultant joint forces during tip pinch function of one
unit force, that is, A = 1. Forces represent the actions of the proximal
segment applied onto the distal segment crossing the joint. CX, joint
compressive joint force; CY, joint dorsal shear force; CZ, joint radial
shear force. (From An KN, Cooney WP III: Biomechanics, section II: the
hand and wrist. In BF Morrey, ed: Joint replacement arthroplasty.
New York, 1991, Churchill Livingstone International, pp. 137-146.)
Figure 6b.6 (A) Each arrow represents the cumulative compressive force vector between adjacent bones and between the carpal bones and
distal ends of the radius and ulna. These joint compressive forces or pressures within the carpus are calculated by this model when all the joints
and ligaments are intact and axial loads are applied along the metacarpals. (B) Predicted displacements of the carpal bones under the loading
condition shown in A. Slight ulnar translation is present as a result of a component of force tangential to the radial articular surface. Carpal bone
displacement must be considered when the concentration of the force vector across articular surfaces is analyzed. The dotted line represents the
unloaded position and the solid line represents the loaded position of the carpus: S, scaphoid; L, lunate; Tq, triquetrum; Tr, trapezium/trapezoid;
C, capitate; H, hamate; R, radius; U, ulna. (C) Each arrow represents the calculated tension for the different carpal ligaments under the same
loading condition: 1, palmar radiolunate ligament; 2, dorsal radiotriquetral ligament; 3, palmar radiocapitate ligament; 4, palmar capitatotriquetral
ligament; 5, dorsal scaphotriquetral ligament; 6, palmar/dorsal hamatocapitate ligaments; 7, flexor retinaculum. (From Horii E, Garcia-Elias M,
Bishop AT, Cooney WP, Linscheid RL, Chao EY: J Hand Surg Am 15A(3):393-400, 1990.)
The effect of joint position and forearm rotation on the percent-
age of load transmission across the radius and ulna has also been
recognized. With the wrist in the neutral position, at the mid-
carpal joint 30% of the total force was transmitted through the
scaphotrapezial joint, 19% through the scaphocapitate joint,
31% through the lunocapitate joint, and 21% through the tri-
quetrohamate joint. With the wrist loaded, the carpal bones
translate in the ulnar direction down the inclined slope of the
distal end of the radius (Fig. 6b.6B), and tensions in the inter-
carpal ligaments are observed as well (Fig. 6b.6C). Interaction
of the carpal bones is conceptually analogous to a Rubiks cube
in which motion in one segment directly affects the position
of another.
POSTTRAUMATIC INJURY
Dobyns et al
6
introduced the concept of traumatic carpal insta-
bilities, and many reports have described their clinical features,
treatments, and long-term consequences. The most common
type of carpal instability is the dorsal intercalated segmental
instability (DISI). Although many reports describe the anatomy
and function of the volar ligaments of the wrists, only recently
has the anatomy of the dorsal ligaments been better detailed
and their function discussed. Most articles, which describe the
pathomechanism of SL instability (SLI), concentrate on the
scaphoid instability. However, there has been relatively little
information about lunate instability and no clear explanation
of the anatomic differences between dynamic and static SLI.
Studies suggested that the DIC ligament is important in main-
taining the carpal alignment of both the scaphoid and lunate.
19
When the DIC and the SL interosseous ligaments were disrupted
from the scaphoid but the DIC was still attached to the lunate,
the resulting carpal instability demonstrated a flexed posture of
the scaphoid and a widened SL gap, but only when the hand was
loaded. This was comparable to a clinical dynamic SLI.
When the DIC ligament was also disrupted from the lunate,
the resulting instability demonstrated a flexed posture of the
scaphoid and a widened SL gap in both loaded and unloaded
conditions. Furthermore, when the DIC was detached from the
lunate, the latter changed position to an extended posture, also
in both loaded and unloaded conditions. This was comparable
with a clinical static SLI with DISI. There was no apparent effect
or further destabilization of the scaphoid or lunate resulting
from disruption of the lunotriquetral interosseous ligament.
The existence and progression of a dynamic SLI to a static SLI
with a DISI deformity resulting from SL dissociation is well
accepted in the clinical setting. To date, however, there has
not been any detailed anatomic explanation and/or example of
what the causes and the differences are between a dynamic
SLI and a static SLI with DISI. The anatomic and mechanical
integrity of the DIC ligament appears to play a significant role
in SL stability and in determining whether the SL dissociation
develops a dynamic or a static instability and DISI deformity.
It is, of course, uncertain whether or not the progressive stages
of instability simulated in these studies reflect actual clinical
injury patterns. These results nevertheless propose that the treat-
ment of the SLI should address not only the SL interosseous
ligament but also the DIC ligament at both its scaphoid and
lunate attachments.
10,19
The second most common site of degenerative changes in
the wrist is scaphoid trapezium trapezoid degeneration. The eti-
ologic factors in the development of degenerative changes in the
STT joint are still unclear; studies have suggested, however, that
degenerative changes are associated with scaphotrapezial ligament
tears and increased trapezium-trapezoid inclination (the degree
of coverage by the facets of the trapezium and trapezoid over the
distal pole of the scaphoid) (Fig. 6b.7).
12
Fractures of the scaphoid (the most commonly broken
carpal bone) are difficult to treat because of its complex three-
dimensional shape and oblique orientation. Fractures of the
proximal pole of the scaphoid have been associated with increased
pressure and degenerative changes in the radius under its distal
pole. Whether the fracture line passes distal or proximal to the
dorsal apex of the ridge of the scaphoid (where the DIC ligament
and the dorsal component of the SL interosseous ligament
attach) appears to determine the likelihood of subsequent DISI
deformity and the pattern of degenerative changes, if the fracture
progresses to a scaphoid nonunion.
11
In the volar type, the
distal fragment displaces volarly with respect to the proximal
fragment, and in the dorsal type, the distal fragment displaces
dorsally.
SUMMARY
Work-related injuries of the hand commonly occur. The nature
of hand function places a tremendous amount of tension and
repetition on the tendons and intrinsic muscles. Although
tension may not be high enough to cause great damage, it can
create compressive and frictional forces on the tendons and adja-
cent tissues around the pulley, bony surface, or other soft tissues.
These compressive and friction forces can potentially cause
cumulative trauma disorders of the bone and soft tissue.
Radiographic TT
inclination
With OA
Without OA
A B
Figure 6b.7 (A) Radiographic measurements in the scaphoid axial
view. Radiographic trapezium-trapezoid (TT) inclination is an angle
formed by a line running axially through the 3rd metacarpal and
another line running from the dorsal to the palmar articular edges of
the proximal trapezium and trapezoid surfaces. (B) TT inclination is
associated with increased osteoarthritis (OA).
REFERENCES
1. An KN, Berger RA, Cooney WP: Biomechanics of the wrist. New York, 1991, Springer-
Verlag.
2. An KN, Chao EY, Cooney WP, Linscheid RL: Forces in the normal and abnormal hand.
J Orthop Res 3:202-211, 1985.
3. An KN, Cooney WP III: Biomechanics. Section II: The hand and wrist. In BF Morrey,
ed: Joint replacement arthroplasty. New York, 1991, Churchill Livingstone
International, pp. 137-146.
4. An KN, Ueba Y, Chao EY, Cooney WP, Linscheid RL: Tendon excursion and moment
arm of index finger muscles. J Biomech 16:419-425, 1983.
5. Chao EYS, An KN, Cooney WP, Linscheid RL: Biomechanics of the hand. A basic
research study. Singapore, 1989, World Scientific.
6. Dobyns JH, Linscheid RL, Chao EY, Weber ER, Swanson GE: Traumatic instability of
the wrist. In A.A.O.S. 1975. St. Louis, MO, 1975, C.V. Mosby, pp. 182-199.
7. Horii E, Garcia-Elias M, Bishop AT, Cooney WP, Linscheid RL, Chao EY: Effect on force
transmission across the carpus in procedures used to treat Kienbcks disease.
J Hand Surg Am 15A(3):393-400, 1990.
8. Kaufman KR, An KN, Chao EYS: Incorporation of muscle architecture into muscle
length-tension relationship. J Biomech 22:943-948, 1989.
9. Lin GT, Amadio PC, An KN, Cooney WP: Functional anatomy of the human digital
flexor pulley system. J Hand Surg Am 14A:949-956, 1989.
10. Mitsuyasu H, Patterson RM, Shah M, Buford W, Iwamoto Y, Viegas SF: Role of the
dorsal intercarpal ligament in dynamic and static scapholunate instability. J Hand
Surg 29(2):279-288, 2004.
11. Moritomo H, Viegas SF, Elder KW, et al: Scaphoid nonunion: a three
dimensional analysis of patterns of deformity. J Hand Surg 25A(3):520-528,
2000.
12. Moritomo H, Viegas SF, Nakamura K, Patterson RM: The scaphotrapezio-trapezoidal
joint: Part 1. An anatomic and radiographic study. J Hand Surg 25A:899-910,
2000.
13. Nakamura K, Beppu M, Patterson RM, Viegas SF: Motion analysis in two dimensions
of radial-ulnar deviation of type I versus type II lunates. J Hand Surg 25A:877-888,
2000.
14. Nakamura K, Patterson RM, Moritomo H, Viegas SF: Type I vs. type II lunates:
ligament anatomy and presence of arthrosis. J Hand Surg 26A:428-436, 2001.
15. ODriscoll SW, Horii E, Ness R, Cahalan TD, Richards RR, An KN: The relationship
between wrist position, grasp size, and grip strength. J Hand Surg 17:169-177,
1992.
16. Patterson RM, Nicodemus CL, Viegas SF, Elder KW, Rosenblatt J: High speed, three
dimensional kinematic analysis of the normal wrist. J Hand Surg 23A(3):446-453,
1998.
17. Stegink Jansen CW, Simper VK, Stuart HG Jr, Pinkerton HM: Measurement of
maximum voluntary pinch strength: effects of forearm position and outcome score.
J Hand Ther:16:326-336, 2003.
18. Viegas SF, Patterson RM, Hokanson JA, Davis J: Wrist anatomy: incidence,
distribution and correlation of anatomy, tears and arthritis. J Hand Surg
18A:463-475, 1993.
19. Viegas SF, Yamaguchi S, Boyd NL, Patterson RM: The dorsal ligaments of the
wrist: anatomy, mechanical properties, and function. J Hand Surg 24A(3):456-458,
1999.
C HA P T E R
6c
Functional Evaluation
of the Wrist and Hand
Jane Bear-Lehman
MULTIDIMENSIONAL ASSESSMENT PROCESS
FOR THE WRIST AND HAND
A comprehensive multidimensional assessment plan for the wrist
and hand requires the selection and use of many different types
of evaluation instruments to measure the outcomes of the
patients health status, impairment level, functional limitations,
and disability status. Assessment focuses on the outcome levels
for those variables that can change because of time, treatment,
or disease.
27
Often generic or condition-specific self-report
questionnaires are now selected to measure health, function, and
disability status from the patients perspective, and performance-
based instruments known as the tools of our trade still provide
data about functional impairment and limitations.
Clinical assessment of the wrist and hand is both a quanti-
tative and a qualitative process. Its aim is to help the clinician
construct and then monitor the effectiveness of the treatment
plan, the progression or the prevention of the disease or injury,
and the health status over time. Treatment of a patient who has
sustained a musculoskeletal occupational injury of the wrist and
hand focuses on helping the patient achieve maximal function
of both body and limb and regain independence in ordinary
activities of daily living while restoring health status.
Occupational musculoskeletal wrist and hand injuries can
result from direct or indirect trauma in the workplace. The injury
affects the musculoskeletal system, which includes the bone, its
joints, and their related structures: muscles, tendons, ligaments,
nerves, and arteries. Direct trauma injuries are usually a medical
emergency; they have a date, time, and place of injury and may
result from a fall in the workplace or adverse physical contact
with tools or machinery. Indirect trauma is microtrauma to the
muscles, tendons, ligaments, nerves, or arteries that persists and
develops over time. The physical performance assessment of a
patient with direct or indirect trauma to the wrist and hand
focuses specifically on the injured and adjacent body parts as
appropriate for the medical and surgical stage of recovery; these
results are compared with function of the uninjured limb, if
available.
Several performance-based instruments that produce quanti-
tative measurements are used in the therapeutic setting to assess
the functional impairment level, including range of motion
(ROM), muscle performance, edema (limb size), and sensation;
functional limitations are assessed using instruments that meas-
ure activities of daily living, dexterity, and physical capacity. This
chapter reviews the performance-based measures for the wrist
and the hand that are considered tools of the trade, with atten-
tion to each instruments stage of development and achieved
reliability and validity. Although it is assumed that the use of
reliable and valid tests increases the statistical probability for
making correct clinical decisions and predictions about per-
formance potential, we are cautioned to not rely exclusively on
these functional impairment or functional performance quanti-
tative data alone. Qualitative data in terms of behavioral response,
such as personal attitude and response to pain, fear, and loss
of control, often influence the quantitative wrist and hand
functional evaluation results.
10
Furthermore, in todays clinic it
is essential to have outcome documentation, including infor-
mation about the patients health status, function, and overall
satisfaction level, to understand the different kinds of results.
3
The clinical assessment of a patient with a musculoskeletal
disorder affecting the wrist and hand follows a biomechanical
frame of reference to evaluate the results or outcomes. The prob-
lems are identified by gathering and then synthesizing subjec-
tive, observational, and objective information about the patient to
determine the quality of the result and the level of satisfaction.
3
This information is derived from the patient, the clinicians
observation of the patient visually and through touch (palpation),
and the outcome measures the patient achieves on administered
self-report and performance-based tests. The assessment relies on
the patients effort and voluntary cooperation with clinical stimuli,
inquiries, and directives.
To begin the assessment, the clinician gathers a history from
the patients perspective about the nature and the course of the
injury, prior medical and therapeutic attention sought, and success
of these interventions. This report from the patients perspective
is compared for congruity with the written medical history.
The clinician poses many questions about life-style adjustment,
to document the alterations but more so to appreciate the
patients ability to recognize, understand, and function within
the restrictions imposed by the present physical problem(s).
Patients are therefore asked to describe how the impact of the
injury has affected their life-styles, namely, the changes in ability
to perform ordinary activities of daily living at home, at work,
and at leisure.
25
The course, location, duration, and type of pain
are addressed through standardized questionnaires, such as the
McGill Pain Profile or the Visual Analog Scale, to detect painful
reaction, patterns about the patients pain, and methods to
control it.
11,30
Outcome self-report instruments are administered to measure
health status and function; some of the measures include infor-
mation about pain level, performance of activities of daily living,
and satisfaction level. Generic or condition-specific scales in
self-report instruments are selected to help standardize the func-
tional assessments. These tools provide the clinician, the patient,
and others with basic functional information that is meaningful
and helps serve as a screen at the outset of treatment.
3
The
SF-36, a widely used generic scale, measures health status in
36 items addressing key elements such as physical function,
physical role, bodily pain, general health, social function, and
emotional role.
40
Many suggest that when assessing a patient
with a wrist or hand injury, the highly regarded SF-36, with its
impressive reliability and validity, should be combined with a
more condition-specific instrument, of which several are avail-
able for selection.
8
Care in selection increases the quality of
Chapter 6c Functional Evaluation of the Wrist and Hand 228
responsiveness and meaningfulness of the information. Attention
should be directed to condition-specific regional self-report tests
on function and health status such as the DASH (disabilities of
the arm, shoulder, and hand), the Michigan Hand Questionnaire,
or the Upper Body Musculoskeletal Assessment for patients who
have upper limb injuries.
8,15,24
More focused questionnaires are
appropriate for specific conditions, such as the Patient-rated
Wrist Evaluation Questionnaire for those who have sustained a
wrist fracture and the Carpal Tunnel Syndrome Questionnaire
for individuals recovering from that syndrome. When matched
with the patient who has the targeted diagnosis, these highly
specific instruments are more responsive than the DASH or the
SF-36.
3,27
In the biomechanical component of the clinical hand and
wrist assessment, the clinician observes the patients posture and
attitude of the injured wrist or hand and its adjacent structures
to answer the following questions: Is the patient favoring a
posture to protect the injured part from environmental contact
through upper extremity flexion and adduction? Is there biome-
chanical alteration in the body to compensate for the poverty
of movement or the increase in pain? Is there symmetry in size
and shape between the injured and uninjured wrist and hand?
Does the body move symmetrically? What are the preferred
postures during static positions such as sitting? What are the
transition patterns, that is, moving from sitting to standing, and
the dynamic patterns of movement such as walking? What is
the quality of movement at the injured site and in the adjacent
structures? Is there a change in coloration at the injured site;
does the coloration vary? Palpation of the skin gives the clinician
more information about the skins temperature, the presence of
nodules, and the tightness of muscle-tendon units.
Physical or anatomic measurement is a continuous and ongo-
ing process; it is carefully coordinated and monitored with the
stage of healing, the plan for movement during healing, and the
trajectory of recovery. Physiologic changes can and do occur
quite rapidly during the acute stage.
18
Objective measures provide
the treating clinician with information about the effectiveness of
a given treatment, confirm the need to continue with a given
treatment regimen, or signal the need for revision if the progress
or response is not as anticipated. The data are used to justify the
need for continuation of treatment or the consideration of other
therapies.
CLINICAL ASSESSMENT OF THE
MUSCULOSKELETAL SYSTEM
Physical performance measurements provide the clinician with
information on the functional impairments affecting the wrist
and the hand. These measurements rely on familiar hand care
tools of the trade; some of the tools or instruments, such as
goniometers for measuring active or passive range of motion,
have remained the same. Others have been further developed
to improve the reliability of the measurement: Hydraulic pinch
meters have replaced spring gauges, for example. Tools have
also been redesigned to improve the quality of measurements, as
in the continual instrument development for the measurement
of light-touch deep pressure sensory response or two-point discrim-
ination testing. Functional impairment requires the assessment
of the wrist and the hand for actual measures of ROM, edema,
muscle performance testing, sensation, and pain, as follows.
Range of motion
Since the 1940s, clinicians have been reporting their use of
the goniometric system to obtain accurate information about
patients joint status and movement capacity. Although techni-
cally not a standardized assessment tool, the universal goniome-
ter is the most widely selected tool for measuring joint ROM.
The American Academy of Orthopaedic Surgeons guide is used
as a reference for normative values.
4
In terms of reliability,
Hamilton and Lachenbruch
20
found no difference in the results
of determining joint angles with different goniometers. The reli-
ability of readings by the same tester over time has shown a
5-degree error when measuring joints in the wrist or the hand.
The method of recording continues to follow the Academy
guideline in which minus sign notation is used to show an exten-
sion limitation and a plus sign indicates hyperextension.
The American Society for the Surgery of the Hand accepted
the method of reporting goniometric scores in terms of the total
arc of movement at a given joint or a related series of joints.
Use of the arc measurement system for the digits is reported as
total active movement and as total passive movement for the
summation of the angles of the three joints in each digit.
14,18
That is, the total active movement or total passive movement
represents the summation of the amount of movement available
in all three joints, the metacarpophalangeal, proximal interpha-
langeal, and distal interphalangeal, with full ROM yields a score
approximating 260 degrees. This composite measurement does
not isolate the individual joint that is creating the deficit, but it
is suited for graphic representations of the patients performance
over time; it is very useful after a tendon or nerve repair.
ROM measurements are conducted on the adjacent joints in
the acute stage of recovery; deficits in the adjacent joints that
were not present before the injury are remediated in therapy.
Depending on the nature of the injury and the medical or surgi-
cal protocol, measurements may be taken for active or passive
ROM at the injury site immediately or may be deferred until
the integrity of the joint or the surrounding tissue allows a meas-
urement. ROM assessment of the injured joints depends on
the type of protection and stabilization used for healing. If com-
plete rest of the injured region is required, measurements are
delayed until movement is permissible. If controlled movement
at the injured site is allowed, the clinician measures the type
of movement (active or passive) within the range allowed and
restricts movement beyond the prescribed arc.
Edema
Trauma or surgery is frequently followed by an abnormal accu-
mulation of fluid in the interstitial spaces of tissues, resulting in
an increase in limb size. This edematous state limits ROM and,
ultimately, function. Measurement of wrist and hand size circum-
ferentially with a tape measure is often done at three locations:
proximal to and distal from the edematous part and over the
edematous part. To allow for a more valid comparison of
sequential measurements, anatomic landmarks are used as refer-
ence points for placement of the tape measure. Placement and
tension of the tape measure or finger gauge affect intertester and
intratester reliability. In the past, clinicians have used jewelers
rings to help reduce the measurement error related to tension on
the tape measure. Now clinicians rely on the Gulick tape, which
has a unique spring gauge, or the finger circumference gauge for
more consistent measurements for repeated measures (Figs. 6c.1
and 6c.2).
Because edema may be not localized in a digital segment but
more generalized over the hand and arm, a volumeter method is
preferred to accurately measure edema changes in the hand and
wrist (Fig. 6c.3). The volumeter, based on Archimedes principle
of water displacement, is used to measure composites of hand
mass. Waylett and Seibly
41
documented 10-ml test-retest reliability
when the manufacturers guidelines are followed.
23
Normative
values for any of these measures are not available; the contralat-
eral side is used as the approximate normal value for that patient.
Because hand-size changes may be attributed to factors other
than edema, such as normal asymmetry or muscle atrophy in the
affected limb from disuse, care must be taken regarding generali-
zation and interpretation of the findings.
Muscle performance testing
Muscle testing is used to evaluate the level of nerve injury and nerve
regeneration and preoperatively to determine potential donors in
tendon transfer surgery. The manual muscle test designed by
Lovett and Martin
26
is a screening device that relies on the
external forces of gravity and resistance to assess muscle strength.
The strength of muscle contractions can be measured clinically
by means of spring scales, dynamometers, weights, or manual
resistance. Manual resistance is added to voluntary maximal
contraction once it has been established that the muscle exertion
and the applied resistance will not adversely affect the healing
bone, joints, and related structures.
There is no agreement regarding whether isometric or isotonic
contraction should be used in muscle testing or whether testing
scores are best derived from the muscles isometric contractibil-
ity under load at the end of the range, which is often chosen as
the point for applied resistance.
22
Few discrepancies are found in
Chapter 6c Clinical Assessment of the Musculoskeletal System 229
Figure 6c.1 Gulick tape measure has a unique spring gauge to
provide consistent measurements. (NC70170-95: Courtesy of North
Coast Medical, Inc., Morgan Hill, CA.)
Figure 6c.3 Hand volumeter is used to measure changes in
hand size. (NC70310.00: Courtesy of North Coast Medical, Inc.,
Morgan Hill, CA.)
Figure 6c.2 Finger circumference gauge is used for consistent
measurement in inches or centimeters. (NC70157-95: Courtesy of
North Coast Medical, Inc., Morgan Hill, CA.)
manual muscle testing procedures. Hislop et al
21
used a gravity-
eliminated position to test metacarpophalangeal joint extension,
whereas Kendall et al
22
did not distinguish the effect of gravity
in the hand. The scoring methods of Lovett and Martin
26
and
Brunnstrom and Denner
13
continue to be used: 0 (zero), 1 (trace),
and 2 (poor) represent test results in the gravity-eliminated posture;
3 (fair) uses the external force of gravity; and 4 (good) and 5
(normal) add the dimension of resistance. Overall, reports of
reliability are descriptive. No predictive validity has been estab-
lished for grip and pinch scores, although many are hypothe-
sized, nor is hand function predictive.
Functional hand strength is measured by grip and pinch tests.
In the case of a distal forearm, wrist, or hand fracture, measure-
ments are deferred for at least 2 to 4 weeks after the removal of
immobilization. Hand strength measurement is the most com-
mon standardized assessment using hydraulic dynamometers.
Figure 6c.4 shows the use of the Jamar hydraulic dynamometer
to measure hand-grip strength. Pinch patterns are measured
using the hydraulic pinch meter (Fig. 6c.5). Spring pinch gauges
are not recommended because they cannot be calibrated and
have yet to prove as reliable or consistent in measuring as
the hydraulic instruments. If regularly calibrated, the hydraulic
hand strength instruments have been shown to be reliable and
produce consistent measurements.
7,18
Both grip and pinch hand
strength instruments allow for readings in kilograms-force and
pounds-force.
The literature shows a variety of test procedures that can
have an impact on interrater and intrarater reliability, as well as
on its normative data pool.
29
The American Society for the
Surgery of the Hand and the American Society of Hand Clinicians
accept the seated posture with humeral adduction and neutral
humeral rotation, the elbow flexed to 90 degrees, and the fore-
arm and wrist in neutral position as the desired body posture for
grip testing.
28
Norms have been established for age 5 to adulthood. Healthy
adult grip strength values for the five handle positions, when
providing full voluntary effort, yield a normal bell-shaped curve.
36
The first position, the closest, is the least advantageous because
it relies primarily on the ulnar nerve-innervated hand intrinsics,
whereas the widest or fifth position relies on the median nerve-
innervated long finger flexors. Middle-range handle positions
require the intrinsic and extrinsic musculature to work together.
A patient without neural or tendon damage who has a flattened
curve may be suspected of providing submaximal voluntary effort.
The traditional pinch patterns of lateral, palmar (also known
as tripod or three-jaw chuck), and tip pinch are reported as
the average of three trials for each type of pinch. The normative
data tables are described on the basis of age and gender for
both grip and pinch. Three test trials are recorded for each grip
and pinch pattern tested. The mean (average of the three), the
standard deviation, and the coefficient of variation (standard
deviation/average) are computed to monitor the consistency or
sincerity of effort.
32,33,36
Sensation
The hand is a complex organ whose function depends on har-
mony between sensory and motor abilities.
16
Sensory testing
Figure 6c.4 The handheld Jamar dynamometer records grip strength
in kilograms-force or pounds-force.
Figure 6c.5 The hydraulic pinch gauge gives accurate and consistent
results, and like the Jamar dynamometer it can be calibrated.
(NC70141_03: Courtesy of North Coast Medical, Inc., Morgan Hill, CA.)
can frequently identify sensorineural changes earlier than tradi-
tional motor examination. Studies have shown, for example, that
in median nerve entrapment at the carpal canal level, sensory
changes precede motor changes. Clinical tests of vibration and
Semmes-Weinstein monofilament testing show changes earlier
than electromyographic studies because the latter does not show
the process of change. Many of the tools used clinically to test
sensation are being revised and improved, and because of
the changes offered by microsurgery, more patients now have
greater potential to achieve sensory results of higher quantity and
quality.
Sensory testing of a patient with a wrist and hand injury
addresses the ability to perceive light touch and deep pressure,
to discriminate touch, and to detect vibration. To monitor the
progress of a patients sensory status, particularly if a neural
injury is suspected, it is advisable to use instruments that yield
ordinal rather than nominal data. Early methods to test light
touch and deep pressure called for the use of a cotton ball or a
cotton-tipped applicator. This form of testing yields the results
that the patient perceived the touch or is normal, may not
have perceived or appreciated the stimulus fully or is impaired,
or did not perceive the stimulus at all or is absent. This hierarchy
represents an ordinal-level data system ranging from normal to
absent response levels; the increment between the values is not
known, nor is it equal. Abnormal results need to be monitored
during the course of treatment. It is expected that sensitivity over
scars and pin tracks is heightened.
The deep pressure-to-light touch interval hierarchy for sen-
sation in the hand resulted from the findings of von Frey,
39
a
surgeon who had a passion for learning about sensation and a
love of horses. von Frey discovered that some of his patients
could detect only the sensation of thicker horse hairs when
applied to their skin surfaces, and as they healed, they could
begin to feel finer horse hairs. The horse hairs that were first used
are now 20 calibrated nylon monofilaments graded in diameter
and individually attached to Plexiglas handles. The amount of
force transmitted is related directly to the diameter of each fila-
ment, which bends at a specific force controlling the magnitude
of the touch-pressure stimulus.
9
Weinstein
42
developed a smaller more portable version of his
original test, the Weinstein Enhanced Sensory Test (WEST), for
ease of use in the clinic. Now clinicians use either the WEST
or the Touch-Test Sensory Evaluators. The latter are individually
calibrated within a 5% standard deviation of the predetermined
targeted force. No other commercially available monofilament
type testing device meets this scrutiny (Fig. 6c.6). The larger set
of 20 still provides greater specificity for those patients who
require it.
To test for discriminatory touch sensation, the static or station-
ary two-point discrimination instrument continues to be chal-
lenged. The original Weber two-point discrimination instruments
sliding scale allowed for adjustment of the spacing between the
two points; however, the adjustment often did not allow the same
precision as a tool with fixed points. Some practitioners open
up paper clips to approximate distances, which leads to variability
in spacing and uneven pressure between points. The two-point
discrimination instrument, the Diskcriminator, designed by
Dellon et al,
17
controls for the precision between points and
provides even application when two points are applied, and the
Touch-Test Two-Point discriminator provides the opportunity
for clinicians to have all points of measure on a single disk
(Fig. 6c.7). Studies show that the amount of pressure offered
when two points are applied can be very different from that of
just one.
The ability to perceive vibratory stimuli is clinically valuable
when the patient has undergone nerve repair or when nerve
compression or a peripheral neuropathy is suspected. The 30-Hz
and 256-Hz tuning forks continue to be used to test for vibratory
response. Clinical studies have proposed that both the 30-Hz
and the 256-Hz tuning forks be used because it is believed
Chapter 6c Clinical Assessment of the Musculoskeletal System 231
Figure 6c.7 The Touch-Test Two-Point discriminator allows for
two-point discrimination testing in one unit. (NC12776A: Courtesy of
North Coast Medical, Inc., Morgan Hill, CA.)
Figure 6c.6 The Touch-Test Sensory evaluators (Semmes-Weinstein
monofilaments) are individually calibrated and accurately measure light
touch-deep pressure. (NC12757: Courtesy of North Coast Medical,
Inc., Morgan Hill, CA.)
that each elicits the response of an individual sensory neurite
receptor. The 30-Hz fork is believed to evoke the response of
the Meissner corpuscle and the 256-Hz fork from the Pacinian
corpuscle.
16
Whether the prong or the stem should be applied
to the skin surface is often debated; in either event, the lack of
control of amplitude and variability in technique make the reli-
ability of the test inconsistent.
7
Furthermore, the patient may
hear the sound of the tuning fork before perceiving it on the skin
surface, confounding the response. Only ordinal data are gleaned
from this form of testing.
A vibrometer with a fixed frequency level provides a result
measured in microns of motion at 120 c/s (Fig. 6c.8). The data
are interval and therefore quantifiable, allowing for specific
tabulation of progress. The raw score is a logarithmic function of
probe displacement measured in volts that is converted mathe-
matically into microns. Normal expected values of the displace-
ment for skin surface are presented in an anatomic diagram and
table format. This instrument requires the use of an electrical
outlet and is not as readily portable as other hand assessment
tools that fit into a laboratory coat pocket.
Pain
Observed during the course of the assessment, pain can be
monitored over time in several ways. Pain is measured as part
of the health and function status at the outcome evaluation by
the use of the McGill Pain Questionnaire or the Visual Analog
Scale,
11,30
and it is monitored as treatment progresses. The patient
is asked to describe the type, location, and threshold of pain per-
ceived before, during, and after each therapy session. Perception
of pain varies from one patient to the next with the same injury
as well as for the same patient over time. The clinician must also
observe and address signs that may be causing pain, such as a
constrictive dressing, cast, or splint or an infection. Pain may and
often does occur at the onset of therapy; this form of pain is
localized and should subside within 2 hours of the session.
FUNCTIONAL ASSESSMENT OF THE
MUSCULOSKELETAL SYSTEM
Critical to the assessment process is to appreciate wrist and hand
use in terms of functional limitations that result from the injury
and to monitor change. Information about functional limitations
can be derived from the self-report questionnaires such as the
generic SF-36, the condition-specific DASH, or the diagnosis
condition-specific Patient-Rated Wrist Evaluation. Performance
tests are administered, and the scores are compared with the
normative tables, if available. The performance scores can be
compared also with the self-report questionnaire findings. Less
often, clinicians may consider direct observation performance
measures for activities of daily living; however, when this occurs,
it is usually to resolve a specific concern or clarify a patients
self-report.
Information processing
The patient comes to the medical setting mainly because of pain,
fear, and disability.
6
A satisfactory result depends not only on the
technical skills of the team but also on the teams ability to com-
municate, engender confidence, and fully understand and explain
the problem to the patient.
12
It is necessary for the clinician to
look at the process of therapy and the patients response to it.
The clinician helps the patient by designing a learning environ-
ment that emphasizes the salient traits and the characteristics of
the problem to be solved or the condition to be learned. One
method is to engage the patient in metacognitive experiences, that
is, conscious thinking and awareness of feelings that accompany
and pertain to the problem-solving task.
1
Flavell
19
defined
metacognitive knowledge as information or beliefs about the
course and outcome of the cognitive enterprise in three areas of
cognitive awareness: person, task, and strategy. Every patient has a
different level of cognitive awareness and a variety of beliefs, feel-
ings, understanding of goals, and strategies for problem solving.
In therapy, practice or instructional programs are systemati-
cally used with a focus on the process rather than the content.
35
Each task is analyzed relative to its repetition, imitation, and
substitution. The training is assessed for the patients need to
have cues or anchors and intermodal training and for the
patients performance in a novel or new learning situation. How
the patient accepts and responds to the information that has
been shared is viewed in more than just a physical sense.
Fear, pain, or side effects of medications often intervene in
the patients ability to orientate to the therapy situation and to
Figure 6c.8 The Bio-Thesiometer Vibrometer measures the threshold
of appreciation of vibration. (Courtesy of Bio-Medical Instrument
Company, Newbury, OH.)
focus attention (alertness); this also affects the patients ability
to learn. A patient in pain may find one voice instrumental in
helping to learn the new way of moving the wrist. A verbal,
visual, or kinesthetic voice (cue) from the clinician may be suffi-
cient as the patient learns to move the wrist and hand again. Two
voices, visual and verbal, may be needed, or the two voices may
bombard the patients ability to concentrate if given at the same
time because of the high threshold of pain. By observing how
the patient learns to move again and how feedback is obtained
and used,
2
the clinician determines whether the patient is reliant
on others for direction and guidance to perform tasks or is self-
directed and self-regulated.
35
It is important to know whether
the patient can detect an error in movement alone, how the error
is corrected, and what kind of reinforcement is required.
The clinician also observes the patients ability to cope with
the injury. After guidance in how to select and terminate activities
that correspond to the patients stage of healing, the clinician
observes how the patient follows such guidelines in performing
ordinary daily tasks, in participating in rehabilitation, and in
assuming societal and family roles. The patient is observed for
the ability to adhere to safety precautions and exhibit self-
control in terms of physical limitations and reactions to pain.
Activities of daily living
The quantity and the quality of the patients performance of
activities of daily living are ascertained by interview. Information
from the self-report health and functional status can be used
or an additional inquiry may be conducted for more specific
information as warranted. For problematic deficit areas, the
clinician may observe the patients actual performance. Early in
the healing process, when medical restrictions are in place as
to the amount of movement or force allowed at the site of injury
or the ability of the injured part to get wet, the patient must be
assessed for methods of accommodation in activities of daily
living.
5
For patients with a wrist or hand injury, this may require
an assessment of eating, personal hygiene, dressing, bathing,
and communication. Adaptive methods and devices may be
indicated temporarily to facilitate one-handed methods, such as
using a rocker knife for cutting meat or a button-hook for fasten-
ing buttons, or the clinician might suggest purchasing precut or
prepared foods.
During the course of the rehabilitation program it is impor-
tant for the clinician to guide the patient as to when and how
the injured wrist and hand can be safely reintegrated into the
performance of activities of daily living corresponding with the
clinical progress. The first reintegration is in the performance of
personal activities of daily living. When strengthening is intro-
duced into the clinical program, the clinician needs to consider
the patients need to perform such instrumental tasks, including
those related to meal preparation, household management and
shopping, and care of others.
For many patients, work during the acute phase of recovery
may not be possible due to extensive manual demands on the
job, whereas others may not have a work interruption. For those
who are working, the clinician identifies the components and
demands of the patients job by interview and helps the patient
assume those tasks that correspond to the achieved clinical
status. For those unable to work, the demands essential to the
patients job are delineated to develop the requirements for
return to work and the goals for therapy. As treatment progresses,
the patients performance level is reviewed and compared
with the levels needed for safe return to work. The feasibility of
meeting the physical demand levels in terms of essentially
required dexterity, strength, or physical endurance are determined
during the rehabilitation process.
Dexterity
Commonly defined as skill and ease in using the hands, dexterity
is considered a functional limitation when impaired. To assess
manual dexterity or physical functioning efficiently, the examiner
must select the standardized test that suits the patients abilities
and needs. Most have a high index of reliability (greater than
0.75) and show good face and content validity; little has been
done on concurrent validity or predictive validity, which is
most needed for the clinical decision-making process.
6
Predictive
validity determines whether the patient, based on the perform-
ance on the test, is ready to return to work. Dexterity tests can
be classified by their demand for fine to gross motor movement
patterns, requirement of one hand or integration of both to
perform the task, requirement of a tool for their administration,
and length of time the test takes to perform.
The Moberg Pick Up test can be classified as a sensory and
dexterity test because it brings together the sensate and motor
functions. This test is usually performed with unrestricted vision
and with vision occluded, and the patient is timed as the famil-
iar objects are scooped, handled, identified, and placed in a
designated location.
The Nine Hole Peg Test (Fig. 6c.9), the Purdue Pegboard (see
Fig. 6c.10), the OConnor Tweezer Dexterity Test, the OConnor
Chapter 6c Functional Assessment of the Musculoskeletal System 233
Figure 6c.9 The Nine-Hole Peg Test quickly measures fine motor
dexterity. (NC34547.d1: Courtesy of North Coast Medical, Inc.,
Morgan Hill, CA.)
Finger Dexterity Test, and the Crawford Small Parts Test are all
examples of fine-motor dexterity movement patterns. However,
the Nine Hole Peg Test and the Purdue Pegboard Test are short
tests that do not provide information about endurance; the
Purdue Pegboard Test does require the use of one hand as well
as that of both hands in a parallel and in an integrated fashion,
as shown in Figures 6c.9 and 6c.10. The OConnor Tweezer
Dexterity Test and the Crawford Small Parts Test both require
the use of a small tool to handle and manipulate the test parts.
The former requires the use of small tweezers, and testing is
completed on the use of one hand at a time for all functions; the
latter requires the use of tweezers or a screwdriver in one hand
while the alternate hand is assistive. The Minnesota Manual
Dexterity Test (Fig. 6c.11) and the Bennett Hand-Tool Dexterity
Test assess gross motor function; the former requires the patient
to handle the test items directly, whereas the latter requires
the use of ordinary mechanics tools. Both allow for the direct
use of both hands during some of the test components. Many
of the Valpar
38
Corporation Work Samples (VCWS) are well suited
to assess precise finger and hand movements. In particular,
the VCWS 1 small tools (mechanical) work sample
38
is helpful in
assessing the use of small tools in tight or awkward spaces requiring
use of the hand(s) without direct visual monitoring.
The outcome scores for manual dexterity performance are
reported as the amount of time (the speed) that the patient
required to perform the task, and the increments of time are
compared with normal data based on age, gender, and occupa-
tion published in the test manuals. The clinician also reports
the preferred prehensile patterns used during the course of the tasks
and the control the patient had over performance. Observations
of motor control are discussed relative to the patients safe use
of the injured part, biomechanical alignment of the injured part
relative to the body, postural accommodation of the body to
the injured part, and quality of task performance. Qualities of
concern include the patients ability to integrate both the injured
hand or wrist and the principles of joint protection sponta-
neously into the dexterity pattern and the ability of the two
hands to work together as a dominant and subdominant pair.
The patient is observed for safety relative to the injured part,
him or herself, and others.
Physical capacity evaluation
Most physicians and clinicians use a physical capacity evaluation
to try to answer the question of whether a patient can safely
return to work. The capacity to perform work may be directly
related to achieved physical performance but is more complex
due to the contribution of both philosophic and psychologic
issues.
34
Many sophisticated instruments are available to assist
in the evaluation process, but the level of validity for these
instruments is less than is often required. Performance on these
systems is interpreted in a variety of ways, including MTM (motion-
times-measurement) standards, U.S. Dictionary of Occupational
Titles Worker Qualification Profiles
37
or U.S. Department of Labor
O*NET.
31
The theoretical model that is followed is Parsons trait
factor from the early 1900s in industrial engineering. The proce-
dure is to identify the traits that the patient now has physically,
behaviorally, and cognitively; to keep symptoms under control
to work safely and effectively; and to match these to envi-
ronmental factors, including the design of the work station, to
determine safe maximum levels of functional work ability in
the work force.
SUMMARY
Success and satisfaction in rehabilitation of the wrist and the
hand is measured by the patients ability to use the injured
Figure 6c.10 The Purdue Pegboard Test has four subtests: right
hand placement, left hand placement, use of the hands in parallel,
and, as shown, integrated use of the two hands on assembly.
Figure 6c.11 The Minnesota Manual Dexterity Test measures eye-
hand-finger movement in two subtests: one-handed placement and two-
handed turn and placement. (NC70030-96: Courtesy of North Coast
Medical, Inc., Morgan Hill, CA.)
part spontaneously in usual, customary, and ordinary activities.
Instruments that produce reliable and valid data assist in account-
ability for the assessment of upper extremity function and restora-
tion of health status. The art of practice requires awareness and
documentation not just of the patients quantitative wrist and
hand dysfunction characteristics, but also of the qualitative ones.
To move effectively and efficiently, the patient needs to learn
again how to do so in a controlled rhythmic way. Todays
practice requires the clinician to use standardized assessments
and report results or outcomes that are meaningful to the clini-
cian, the patients, and all who have access to the information.
Using an outcome model allows the clinician to understand
what is happening to the patients who are treated.
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Chapter 6c References 235
C HA P T E R
6d
Wrist and Hand:
Treatment Options
David M. Kalainov and Mark S. Cohen
Disorders of the wrist and hand are common in the work
environment.
23
Effective management frequently depends on a
multidisciplinary approach with coordinated input from a physi-
cian, hand therapist, and nurse case manager. This chapter
reviews several wrist and hand conditions that may occur in
an occupational setting, including tendinitis, peripheral nerve
compression lesions, sprains, fractures, arthritis, ganglia, and
complex regional pain syndrome. The underlying pathologies,
diagnostic methods, treatment options, and projected outcome
for the various conditions are discussed.
TENDINITIS
Tendinitis is a general term used interchangeably with tenosyn-
ovitis, stenosing tenosynovitis, and tendovaginitis. A thin
low-friction envelope that surrounds individual tendons, the
tenosynovium, enhances tendon gliding around bony promi-
nences and through retinacular sheaths. Tenosynovitis, which
refers to inflammatory changes in this lining, is often associated
with a systemic disease process. A more frequently encountered
condition, termed stenosing tenosynovitis or tendovaginitis, involves
thickening of the tendon and overlying retinacular sheath with
only a paucity of tenosynovial inflammation. de Quervain disease
and trigger digit are two common examples.
de Quervain disease
The dorsal wrist is comprised of six retinacular compartments
encompassing the extensor tendons of the wrist and hand.
The first compartment, which contains the abductor pollicis
longus and the extensor pollicis brevis tendons, is located directly
over the styloid process of the distal radius (Fig. 6d.1). Painful
restricted tendon motion through this compartment is referred
to as de Quervain disease.
19
de Quervain disease is frequently associated with activities
involving repetitive flexion and extension of the thumb and ulnar
deviation of the wrist. The condition is also associated with direct
trauma, rheumatoid arthritis, gout, and diabetes mellitus. A subdi-
vision of the compartment by a septum is thought to predispose
some individuals to the development of this condition.
A patient with de Quervain disease presents with symptoms
of pain, swelling, and tenderness over the radial styloid. Pain
can be quite severe, with guarding and limitation of wrist and
thumb motion. Crepitation with thumb flexion and extension
is occasionally palpable as are small ganglia arising from the
diseased compartment. The best objective tool in confirming
the diagnosis of de Quervain disease is the Finkelstein test. By
maximizing the excursion of the tendons through the stenotic
first dorsal compartment, this maneuver produces significant
discomfort for the patient if the condition is present.
Conservative treatment options for de Quervain disease include
splinting, corticosteroid injections, nonsteroidal antiinflamma-
tory medication, temporary job modifications, and therapy.
Splinting alone may be beneficial for management of acute pain,
but symptom recurrence is common. A single corticosteroid
injection into the first extensor compartment successfully relieves
pain in 60% of cases, whereas two injections may provide relief
in up to 80% of cases. Because the soft tissue in this region is thin,
however, repeated corticosteroid injections, with infiltration into
the subcutaneous tissues, can lead to localized depigmentation,
fat necrosis, and subcutaneous atrophy.
If conservative measures fail, surgical release of the first
extensor tendon compartment may be considered. Surgery
involves incision of the retinacular sheath and division of
any septae separating the abductor pollicis and extensor pollicis
brevis tendons. Vigorous retraction or injury of skin sensory
nerves intraoperatively can cause periincisional pain and/or
numbness. A therapist may be helpful in the early postoperative
period with scar desensitization and strengthening exercises.
Release of the first dorsal compartment predictably leads to a
satisfactory result in over 90% of cases. Patients are generally
able to return to unrestricted employment within 6 to 8 weeks
after surgery.
Trigger finger
The flexor tendons projecting to each digit enter a retinacular
sheath that begins in the distal palm. Thickening of the tendons
and sheath at this point may obstruct normal tendon gliding,
leading to catching and locking of the digit (Fig. 6d.2).
Figure 6d.1 Wrist and finger extensor tendons. The first dorsal
compartment contains the abductor pollicis longus and extensor
pollicis brevis tendons (arrow). Painful restricted tendon motion through
this compartment is referred to as de Quervain disease.
Chapter 6d Wrist and Hand: Treatment Options 238
Examination often reveals a tender nodularity in the distal palm
that moves with excursion of the tendons.
26
Conservative care of a trigger digit entails activity modifica-
tions and a corticosteroid injection into the proximal flexor ten-
don sheath. Single finger involvement, a discreet palpable nodule,
and a short duration of symptoms are favorable prognostic
indicators. Splinting of the metacarpophalangeal joint for a brief
period may be added to the treatment regimen. In individuals
whose symptoms are aggravated by the use of small tools, modi-
fication of these instruments to distribute forces over a greater area
with a lesser requirement for digital flexion may be beneficial.
The reported success rates after an injection range from
60% to 84%. If conservative management fails, surgical treat-
ment may be considered. Incision of the proximal portion of
the flexor tendon sheath in the palm is curative in over 95% of
cases. Most patients are capable of returning to unrestricted work
activities within 4 to 8 weeks postoperatively.
Other tendonopathies
Intersection syndrome refers to tenosynovitis of the radial wrist
extensor tendons where they cross the first dorsal compartment
tendons in the distal forearm. Pain is typically localized to an
area four fingerbreadths proximal to the radial styloid. Often,
palpable and audible crepitus occurs in this region with active
wrist motion. Other tendons occasionally involved by inflam-
mation and stenosis include the flexor carpi radialis, the exten-
sor carpi ulnaris, and the extensor pollicis longus. In these cases,
nonoperative treatment measures that may include splinting,
ice, corticosteroid injection(s), antiinflammatory medications,
activity modifications, and therapy are usually successful.
CARPAL TUNNEL SYNDROME
The median nerve passes across the wrist through an unyielding
fibroosseous canal, termed the carpal tunnel (Fig. 6d.3).
Compression of the median nerve within this space is termed
carpal tunnel syndrome. The condition occurs due to a mismatch
between the volume of the canal and its contents: the median
nerve and the nine digital flexor tendons.
Carpal tunnel syndrome is associated with diabetes, hypothy-
roidism, rheumatoid arthritis, and renal failure. Other contribu-
tory risk factors include wrist fractures, aging, obesity, female
gender, smoking, pregnancy, and alcoholism. In the workplace,
carpal tunnel syndrome has been attributed to repetitive forceful
use of the wrist and digits, repeated impact on the palm,
and operation of vibratory tools. Task-related factors, however,
are variable and inconsistent, and the mechanisms by which they
may contribute to carpal tunnel syndrome are poorly understood.
The diagnosis of carpal tunnel syndrome relies initially on
the patient history.
8
Symptoms may include tingling and numb-
ness in the thumb and central digits, burning pain, weakness,
and clumsiness of the hand, all corresponding to the motor and
sensory distributions of the median nerve. Symptoms often
appear after prolonged wrist flexion while sleeping and extended
periods of wrist extension while driving. Loss of sensation (in the
radial four digits) and atrophy of the thenar eminence muscles
are symptoms of advanced median nerve compression.
Carpal tunnel syndrome is diagnosed primarily through
physical examination, including evaluation of thenar muscle
Figure 6d.2 Digital flexor tendon sheath. Thickening of the tendons
and sheath proximally may lead to triggering (arrow).
Figure 6d.3 Wrist magnetic resonance image, axial view. The carpal
tunnel (white arrow) contains the median nerve and the nine flexor
tendons. The adjacent ulnar tunnel (black arrow) contains the ulnar
nerve and artery.
bulk and strength and performance of sensibility testing. A vari-
ety of provocative maneuvers is used to reproduce or accentuate
the symptoms. Phalens test refers to placing the wrist in a fully
flexed posture, whereas Tinels test refers to percussion of the
median nerve over the wrist. The median nerve compression test
involves direct pressure on the median nerve over the carpal
canal. An electrodiagnostic study may be obtained to confirm
the diagnosis of carpal tunnel syndrome and to quantify the degree
of median nerve injury.
In the absence of diminished sensation, muscle atrophy, or
denervation potentials on electrodiagnostic testing, initial treat-
ment for carpal tunnel syndrome involves splinting the wrist
in neutral alignment and injecting corticosteroid into the carpal
canal.
11
A neutral wrist position relaxes the median nerve and
maintains a low pressure in the carpal tunnel. Splinting and
injection provide short-term relief of symptoms in over 75%
of patients and continued symptomatic relief for 1 year or more
in 13% to 40% of patients diagnosed early with mild symptoms.
Presence of symptoms for less than 12 months, intermittent
numbness, male gender, absence of advanced sensory changes,
and normal thenar muscle bulk are good prognostic indicators
for success.
Activity modifications and use of antivibration gloves are
encouraged in manual laborers.
16
Associated systemic diseases
such as diabetes and hypothyroidism should be recognized
and appropriately managed. Ergonomic changes may be consid-
ered for general patient comfort and satisfaction. Many recom-
mended measures have not, however, been scientifically proven
to prevent or ameliorate symptoms of carpal tunnel syndrome.
If patients experience only partial or temporary relief with
conservative treatment measures, surgical decompression of
the carpal tunnel may be considered. Individuals who report at
least temporary relief after an injection are more apt to obtain
similar relief from carpal tunnel release surgery.
10
Newer tech-
niques such as limited-incision carpal tunnel releases and those
performed endoscopically have been developed to decrease
palm discomfort and allow for a more rapid return to activities.
Compared with a standard open decompression, the endoscopic
procedure has been found to shorten the recovery period, but
it may be associated with a higher reoperation rate and possibly
an increased risk of nerve injury.
20
Operative release reliably diminishes tingling in the digits,
whereas improvements in numbness and weakness are less
predictable. In patients with severe chronic nerve compression, it
is not unusual to have permanent low-grade symptoms after
uncomplicated carpal tunnel release surgery. Palm sensitivity
around the scar, referred to as pillar pain, is fairly common
and can be helped by scar desensitization performed by an occu-
pational therapist. Activity restrictions in a manual laborer are
typically recommended for a period of 6 to 8 weeks after surgery,
with maximum medical improvement anticipated between 3 and
6 months postoperatively. Successful carpal tunnel release surgery
usually produces no permanent impairment.
ULNAR TUNNEL SYNDROME
Neuropraxia of the ulnar nerve at the wrist is referred to as ulnar
tunnel syndrome.
3
The ulnar tunnel, or loge of Guyon, is a
fibroosseous space adjacent to the carpal tunnel through which
passes the ulnar nerve and artery. Compression of the ulnar nerve
at this site can occur from trauma, use of vibrational tools, ulnar
artery thrombosis or aneurysm, or presence of a space-occupying
lesion such as a ganglion cyst. Symptoms include intrinsic
muscle weakness, numbness, and tingling in the ring and small
fingers, or a combination of motor and sensory abnormalities.
The diagnosis depends on a thorough physical examination
and pertinent ancillary studies. The examination should include
palpation, percussion, vascular and motor evaluations, and
sensory testing. Wrist radiographs are helpful in excluding a
hook of hamate fracture in patients with a history of trauma.
Magnetic resonance imaging (MRI) or an ultrasound study may
be valuable in identifying a ganglion cyst, ulnar artery aneurysm,
or arterial thrombosis. An electrodiagnostic study can assist in
locating the anatomic site of compression and in determining
the severity of the nerve involvement.
If a specific etiology for ulnar tunnel syndrome is identified,
treatment is directed toward the cause. Examples include excision
of a space-occupying lesion, resection of an arterial aneurysm,
and repair or resection of a hook of hamate fracture. When no
cause is found, conservative treatment measures such as wrist
splints, antivibration gloves, activity modifications, and non-
steroidal antiinflammatory medication are instituted. Surgery is
considered in these patients only if the diagnosis is certain and
nonoperative modalities fail. The procedure involves decom-
pression of the ulnar nerve and artery in the proximal palm.
Most patients with ulnar tunnel syndrome without a struc-
tural lesion do well with nonoperative management. In patients
managed surgically, assistance from an occupational therapist
may be beneficial in the early postoperative period. Most patients
are able to return to previous employment activities in 6 to
8 weeks, with maximum medical improvement expected from
3 to 6 months postoperatively.
An uncommon cause of ulnar tunnel syndrome that deserves
special mention is the hypothenar hammer syndrome.
6,9
This
condition results from repetitive impact to the ulnar aspect of
the hand leading to ulnar artery damage and formation of a
pseudo-aneurysm and/or clot. Clinical findings include local
tenderness and ischemic changes with numbness in the ring
and small fingers. A pathologic Allen test with compression of
the radial artery and impaired blood flow to the ulnar digits sup-
ports the diagnosis. The location of the lesion can be determined
with ultrasonography, selective angiography, or MRI angiography.
Initial treatment of hypothenar hammer syndrome includes
cessation of impact trauma to the hand, elimination of tobacco
products, and avoidance of prolonged cold exposure. Arterial
thrombosis may be addressed nonoperatively in some indi-
viduals with injection of a thrombolytic agent or surgically in
others by resecting the damaged vessel segment. Because of the
potential for repeated thrombi formation and emboli to the dig-
ital arteries, an aneurysm is best managed operatively. Although
residual cold intolerance can be expected, the results of surgical
treatment are generally good.
HAND-ARM VIBRATION SYNDROME
Hand-arm vibration syndrome, or vibration white finger, is a
complex condition associated with vibration exposure and
the use of hand-held vibrating tools.
14,18,22
Symptoms include
Chapter 6d Hand-Arm Vibration Syndrome 239
white fingers, sensory disturbances, reduced hand dexterity, and
diminished grip strength. Additional symptoms may include
cold intolerance, wrist and hand pain, and muscle cramps.
Vibration exposure has a cumulative effect on both vessels and
nerves. The duration of exposure necessary to elicit symptoms,
however, has never been clearly defined.
The diagnosis of hand-arm vibration syndrome is based on a
history of vibration exposure and the presence of symptoms. The
Stockholm workshop scales are widely used in assessing the
severity of this condition in affected individuals. Electrodiagnostic
and vascular flow studies are helpful in excluding other etiolo-
gies such as an arterial thrombosis or peripheral nerve compres-
sion lesion, although separate conditions may coexist.
Prevention of hand-arm vibration syndrome is of paramount
importance, with measures including use of well-padded antivi-
bration gloves and frequent breaks from operating vibratory
machinery. If symptoms develop, avoidance of the inciting tool(s)
is essential. Discontinuation of smoking, oral vasodilators, and
limitation of cold exposure may be beneficial in reducing associ-
ated digital vasospasms. In early stages, the condition is typically
reversible, but in long-standing cases, blanching of the fingers
may persist indefinitely despite avoidance of vibration exposure.
SPRAINS
A sprain constitutes an injury to one or more ligamentous
structures stabilizing a joint. The complex anatomy of the wrist
ligaments includes thickened bands of capsular tissue inter-
connecting the distal radius to the distal ulna and carpal bones,
along with deeper structures such as the scapholunate and
lunotriquetral interosseous ligaments linking adjacent carpal
bones. The finger metacarpal and interphalangeal joints are
stabilized by medial and lateral capsular thickenings termed
collateral ligaments and a strong palmar structure designated
the volar (palmar) plate.
Scapholunate interval
Stability of the scapholunate interval depends on the integrity of
the scapholunate interosseous ligament and secondary capsular
ligament restraints.
31
A history of falling onto the affected hand
is often described in association with a scapholunate interval
injury, the symptoms of which include dorsoradial wrist pain
and a weakened grasp. Occasionally, active wrist flexion against
resistance produces a painful snapping sensation.
The diagnosis is suspected when pain is elicited with finger
pressure over the scapholunate interval. The scaphoid shift test
is helpful in excluding other causes of dorsoradial wrist pain,
such as a ganglion cyst. A positive shift test is noted if the
proximal pole of the scaphoid can be translated over the dorsal
rim of the radius under dynamic load.
In the initial evaluation, plain radiographs are useful. If an
abnormality in carpal bone spacing is detected, comparative
views of the contralateral wrist are obtained to distinguish a
normal variation in carpal spacing from pathologic carpal align-
ment. In equivocal cases, fluoroscopic imaging can be helpful.
Additional studies that may assist in making the diagnosis
include wrist arthrography (Fig. 6d.4), MRI arthrography, and
arthroscopy.
Initial nonoperative management is indicated for acute and
stable scapholunate interval injuries. Individuals with partial
ligament tears and no clinical or radiographic evidence of carpal
instability can be treated by temporary wrist immobilization.
A nonsteroidal antiinflammatory medication and a localized
cortisone injection may also be considered. Patients with chronic
scapholunate ligament tears and evidence of marked degenera-
tive arthritis can be initially managed similarly. If symptoms
persist beyond approximately 4 months, surgical options may
be discussed.
In patients with acute and unstable scapholunate ligament
injuries, early operative intervention is recommended. The deci-
sion to intervene surgically, however, depends on additional
factors, including patient age, health status and expectations,
and anticipated compliance with postoperative care. Because
most individuals who sustain an acute scapholunate interval
injury are physiologically young and active, direct ligament
repair with capsular augmentation is perhaps the best means
of managing this injury. However, other surgical procedures
Figure 6d.4 Wrist arthrogram. Radiopaque dye injected into the
radiocarpal interval with leakage into the midcarpal and distal
radioulnar joints. The appearance is diagnostic for tears of the
scapholunate and lunotriquetral ligaments and the triangular
fibrocartilage complex (TFCC).
have been described for treatment of both acute and chronic
scapholunate interval trauma. Depending to a large degree on
the specifics of the surgery, the course of rehabilitation and the
results of treatment vary.
Lunotriquetral interval
Analogous to scapholunate instability, pathologic laxity of
the lunotriquetral interval requires injury to both the lunotrique-
tral interosseous ligament and the secondary capsular restraints.
27
The spectrum of pathology ranges from partial ligament tears
with retained carpal stability to complete dissociation with carpal
collapse. Symptoms may include pain and crepitus with dimin-
ished wrist motion, grip weakness, and sensation that the carpus
is giving way.
To differentiate a lunotriquetral interval injury from other
lesions that can cause ulnar-sided wrist symptoms, a careful
examination is necessary. Palpation over the lunotriquetral joint
predictably elicits pain. A ballottement test, performed by grasp-
ing the pisotriquetral unit between the thumb and index finger
of one hand and the lunate between the thumb and index finger
of the other hand, reproduces symptoms and may demonstrate
abnormal joint laxity.
Plain radiographs are recommended in the evaluation of
ulnar-sided wrist pain. Lunotriquetral instability may not be
readily apparent on standard radiographic images, however. An
MRI arthrogram can assist in diagnosis and occasionally reveal
other lesions contributing to the symptom complex.
Initial management is typically nonoperative, involving
activity modifications and a 4- to 6-week course of wrist immo-
bilization. A midcarpal corticosteroid injection and short-term
use of an antiinflammatory medication may be beneficial also.
Most patients with isolated lunotriquetral ligament tears respond
well to conservative treatment.
Persistent pain localized to the lunotriquetral interval with
failure of conservative management is an indication to intervene
surgically. The result depends on a variety of factors, including
chronicity of the injury, associated carpal arthrosis, and specifics
of the operation performed. Surgical options include simple
ligament debridement, shortening of the ulna to decompress
the lunotriquetral joint, lunotriquetral ligament reconstruction,
and lunotriquetral fusion. Poor response to a previous injection
and/or immobilization is a strong indicator of a potential surgical
failure.
Triangular fibrocartilage complex
The triangular fibrocartilage complex (TFCC) is a soft tissue
structure composed of seven contiguous elements that combine
to stabilize the distal radioulnar joint and suspend the ulnar
carpus.
15
Traumatic disruption of the TFCC can lead to ulnar-
sided wrist pain, instability of the distal radioulnar joint, and
articular cartilage degeneration.
Patients typically describe pain and a clicking sensation
localized to the ulnar aspect of the wrist after known injury
or repeated microtrauma. Symptoms are often aggravated by fore-
arm rotation and ulnar deviation of the wrist. Applied pressure
in the soft tissues distal to the tip of the ulnar styloid
predictably elicits discomfort. Stress testing of the stabilizing
function of the TFCC is performed by applying dorsal and
palmar pressure to the interval between the distal ulna and the
carpus. Wrist radiographs are recommended to assess arthritic
changes, carpal instability patterns, and ulnar bone length relative
to the radius (ulnar variance). MRI with or without intraarticular
contrast may assist in the diagnosis.
In most patients, initial treatment of a TFCC injury involves
a variable period of wrist immobilization and possibly a corti-
sone injection into the ulnocarpal joint. Exceptions include the
rare traumatic tear with gross instability at the distal radioulnar
joint. These cases usually require early operative intervention.
In those individuals who fail conservative measures and have
significant symptoms, surgical intervention may be indicated.
Simple arthroscopic debridement is effective in the management
of many traumatic TFCC lesions, especially central tears
(Fig. 6d.5). In individuals with positive ulnar variance or lunotri-
quetral instability, this can be combined with formal ulnar short-
ening. Open or arthroscopically assisted repairs of a peripheral
tear have exhibited results similar to or better than debridement
alone. The expected postoperative recovery period depends to
a large extent on the details of the operation performed. After
discontinuation of splint immobilization, all patients may
benefit from a short period of therapy. Maximum medical
improvement is expected 3 to 6 months postoperatively.
Chapter 6d Sprains 241
Figure 6d.5 Wrist arthroscopy.
Gamekeepers thumb
Disruption of the ulnar collateral ligament of the thumb
metacarpophalangeal joint occurs when a significant valgus stress
is applied to the joint,
13
often from a fall on the outstretched
thumb. The injury may result in metacarpophalangeal joint
instability, causing pain with thumb motion and adversely affect-
ing both grip and pinch strength. Two terms commonly used
to describe this injury are the gamekeepers thumb and the
skiers thumb.
The anatomy of the thumb ulnar collateral ligament is
analogous to that of the collateral ligaments stabilizing the fin-
ger metacarpophalangeal and interphalangeal joints. The thumb
ulnar collateral ligament ruptures most often from its distal
insertion at the base of the proximal phalanx. Displacement of
the ligament can occur such that it comes to lie superficial and
proximal to the adductor pollicis muscle, a specific pattern of
injury referred to as a Stener lesion (Fig. 6d.6).
The diagnosis of a gamekeepers injury involves a careful
examination of the involved thumb. Plain radiographs should
be obtained to assess for an underlying bone injury. Stress radi-
ographs with applied valgus force to the metacarpophalangeal
joint can confirm the diagnosis and determine the degree of
ligament disruption. Treatment of partial ligament tears involves
a 4- to 6-week period of thumb immobilization. A hand-based
spica splint or cast incorporating the thumb proximal phalanx
usually suffices. A complete ligament tear is an indication for
surgical intervention; in these cases a Stener lesion may preclude
effective ligament healing with nonoperative treatment. The
thumb is commonly immobilized for 4 weeks postoperatively.
Unrestricted activities are permitted after 6 weeks in cases treated
nonoperatively and after 3 months in patients managed surgically.
In thumbs with partial ligament injuries, nonoperative
treatment yields a stable and painless thumb with near-normal
motion in most cases. In thumbs with a complete ligament
rupture treated early with surgery, more than 90% of patients
can expect a good to excellent result.
Fingers
The finger metacarpophalangeal and interphalangeal joints
may be injured by a variety of different mechanisms, resulting in
partial or complete disruption of the collateral ligaments and
palmar plate. Although the closely conforming articular surfaces
of the proximal and distal interphalangeal joints usually afford
residual stability, the metacarpophalangeal joints are less anatom-
ically constrained and may exhibit pathologic laxity with injury
to identical periarticular structures.
The diagnosis of a finger sprain is relatively straightforward.
The involved joint exhibits variable swelling and limited motion
with maximum tenderness in the area of soft tissue injury. Gentle
stress may elicit visible or palpable joint instability. Assessment
and documentation of neurovascular status commonly reveals
a digital neuropraxia. Radiographs are valuable in excluding
the presence of a fracture, joint subluxation, or joint dislocation.
Ultrasound and MRI studies may be considered but are often
unnecessary for initial diagnosis.
A stable sprain of the finger metacarpophalangeal joint is
treated with buddy strapping and immediate motion. Velcro
straps or athletic tape is placed around the injured digit and
adjacent finger, leaving the interphalangeal joints free for motion
exercises. An unstable metacarpophalangeal joint may be
managed by buddy strapping and/or immobilization in a hand-
based splint for 4 to 6 weeks. The decision to intervene surgically
depends on several factors, including the presence of an associ-
ated avulsion fracture and residual joint instability with splint
immobilization.
Sprains of the proximal and distal interphalangeal joints
are managed by finger extension splinting for a brief period fol-
lowed by active motion exercises and protective buddy strap-
ping. Progressive static or dynamic extension splinting may be
indicated during the course of treatment to address a developing
joint contracture. Supervised therapy is often helpful.
Most finger sprains can be managed without surgical inter-
vention. Some degree of permanent swelling is expected, and a
small flexion contracture may persist. The deformity will unlikely
impair hand function or preclude a return to gainful employment.
FRACTURES
Distal radius
Distal radius fractures, commonly called Colles, Bartons, Smiths,
and Chauffeurs fractures, account for 14% of all extremity
injuries.
12,24
Approximately 50% of these injuries involve the
articular surface of the distal radius. In healthy and active
individuals, restoration of bone and joint alignment is indicated
to preserve function and to deter posttraumatic arthrosis.
The initial examination should include an assessment for
concurrent bone and soft tissue injuries with specific attention to
the stability of the distal radioulnar joint. Although vascular
compromise occurs rarely, neurologic symptoms are relatively
Figure 6d.6 Torn and displaced ulnar collateral ligament of the
thumb metacarpophalangeal joint, termed a Stener lesion (arrow).
This pattern of displacement is often responsible for failure of
nonoperative management of complete ligament tears.
frequent and typically involve the median nerve in the carpal
tunnel with paresthesias in the radial four digits.
Radiographic evaluation is performed both before and after
attempted closed fracture reduction (Fig. 6d.7). Assessment of
the intraarticular extent of the injury is crucial. A residual joint
incongruity of 2 mm or greater displacement has been associated
with posttraumatic arthrosis. Special imaging studies such as
computed tomography are useful when the fracture pattern
and/or magnitude of displacement is difficult to determine on
plain radiographs.
Closed stable fractures in acceptable alignment can be treated
nonoperatively. Serial radiographs are obtained, and a cast is
worn for approximately 6 weeks, followed by the use of a tem-
porary removable splint. Supervised therapy may be helpful
early during the course of healing to assist with finger motion
and later, after fracture consolidation, to help improve wrist
motion and grip strength. Displaced and unstable fractures
usually require surgery. Procedural options include the use of
percutaneous pins, external fixation, open reduction and internal
fixation, or a combination of methods.
The results of treatment vary, depending in part on the sever-
ity of the initial injury and the extent of articular surface involve-
ment. Although maximum medical improvement is anticipated
6 months after injury or surgery, patients may continue to
demonstrate improvements in wrist motion, grip strength, and
endurance for well over 1 year.
Scaphoid
The scaphoid is the most commonly fractured carpal bone.
7
This type of injury typically results from a sudden impact on the
palm with the wrist hyperextended, such as occurs with a fall
onto the outstretched hand. When the fracture is complete,
intrinsic forces may lead to displacement of a scaphoid fracture
into a flexed humpback position: The proximal pole extends,
whereas the distal pole flexes.
Classically, the patient presents with loss of wrist motion,
snuff box tenderness, and pain with resisted forearm pronation
and supination. Wrist swelling may be present, but this and
other signs of local trauma are not always apparent. In many
instances the presentation and diagnosis are delayed, with the
injury initially attributed to a sprain. Although most scaphoid
fractures can be detected acutely on good quality plain radio-
graphs (Fig. 6d.8), some do not become apparent for several
weeks. Specialized imaging studies, including MRI, scintigraphy,
and computed tomography, are occasionally helpful in early
diagnosis and subsequent management.
Closed treatment is indicated for acute nondisplaced
scaphoid fractures. If diagnosed promptly and immobilized
for an adequate duration, more than 90% of stable scaphoid
injuries heal. Surgical intervention is indicated for acute fractures
that are either displaced or unstable and for older fractures that
have failed to unite. Instability is defined as displacement greater
Chapter 6d Fractures 243
Figure 6d.7 Displaced distal radius fracture (arrow). Figure 6d.8 Scaphoid waist fracture (arrow).
than 1 mm in any direction and injuries associated with loss
of carpal bone alignment. Relative indications for surgical treat-
ment include a proximal pole fracture and prolonged wrist
immobilization that would be unacceptable to the patient for
social and/or economic reasons.
Intramedullary pins or screws have become the standard of
fixation for scaphoid fractures, with union rates comparable
with those reported for closed-cast treatment. When screws are
used and stability is achieved, early mobilization of the wrist is
often permitted. In one study of military personnel, percutaneous
screw fixation of nondisplaced scaphoid fractures was shown to
result in more rapid radiographic union and return to duty when
compared with cast immobilization.
5
Maximum medical
improvement is expected 4 to 6 months after injury or surgery
but is contingent upon fracture healing.
Metacarpals and phalanges
Fractures involving the metacarpals and phalanges occur in
multiple patterns: transverse, oblique, spiral, and comminuted.
4,17
Most of these injuries may be evaluated using standard radio-
graphs. The rotational alignment of the digit is assessed with
active finger motion or by generating finger motion through a
tenodesis effect with passive wrist flexion and extension. The
phalanges should be parallel during extension and point toward
the thenar eminence when flexed.
Most metacarpal and phalangeal shaft fractures can be treated
nonoperatively with protective casting or splinting. Clinical
union usually requires 4 to 5 weeks for metacarpal injuries and
3 to 4 weeks for proximal and middle phalanx injuries. A distal
phalanx fracture may take longer to unite. Metacarpal fractures
are typically immobilized with a forearm-based cast or splint
incorporating the metacarpophalangeal joint of the injured
finger and one or two adjacent digits. Hand-based immobiliza-
tion is indicated for proximal and middle phalanx shaft fractures,
whereas distal phalanx fractures are treated with a simple finger
splint. All cases require close radiographic follow-up to assess
for loss of fracture alignment.
Operative treatment is indicated for irreducible or unstable
fractures and those associated with tendon lacerations. Articular
injuries with marked incongruency and/or persistent joint
subluxation are also considered for surgical repair. The type of
fixation used depends on the fracture pattern, the soft tissue
injury, and the judgment and experience of the surgeon.
Depending in part on the severity of the fracture and associ-
ated soft tissue trauma, the reported results after nonoperative
and operative treatment of metacarpal and phalangeal fractures
are variable. A successful outcome requires patient compliance
with treatment and an appropriately structured rehabilitation
program. In most cases maximum medical improvement is antici-
pated approximately 3 to 4 months from injury or surgery.
OSTEOARTHRITIS
Osteoarthritis is a slowly progressive joint disease of multifactorial
etiology.
21,29
Cartilage degeneration and osteophyte formation
are often seen in association with advancing age, characteristically
affecting the hands symmetrically. The distal interphalangeal
joint of the finger is the most commonly involved hand joint,
followed by the thumb basilar joint. In contradistinction to sys-
temic arthritic conditions such as rheumatoid arthritis, the finger
metacarpophalangeal joints are usually spared. Although several
studies have alluded to repetitive activities as having an influence
on the development of osteoarthritis in the wrist and hand, a
causal relationship between repetitive activities and degenerative
joint disease has never been conclusively proven.
Wrist
Osteoarthritis of the wrist most often develops secondary to
a traumatic event. Intraarticular fractures of the distal radius,
malunited scaphoid fractures, scaphoid nonunions, and inter-
carpal ligamentous injuries all predispose the wrist to degenera-
tion. In many cases, however, a specific cause is never identified.
Patients with wrist arthritis report pain, loss of mobility, and
weakness in grip. Crepitation during motion or loading activities
and swelling over the dorsal carpus are common in advanced
disease. Plain radiographs confirm the diagnosis and assist in
devising a treatment strategy (Fig. 6d.9).
For early degenerative disease of the wrist, conservative
measures are frequently successful. These include nonsteroidal
Figure 6d.9 Wrist degenerative arthritis developing after a
scapholunate interval injury (arrow).
antiinflammatory medication, wrist immobilization, activity
modifications, and corticosteroid injection(s). Significant
degenerative arthritic changes predict some degree of permanent
functional impairment.
Surgery is indicated if symptoms warrant and conservative
treatment measures have failed. Procedures include proximal
row carpectomy (excision of the three most proximal carpal
bones), partial carpal bone fusions, and total wrist arthrodesis.
The period of postoperative immobilization depends on the
specifics of the operation performed, averaging 6 to 8 weeks
for a fusion procedure.
Results of surgical treatment are favorable in terms of pain
relief. Motion-retaining procedures such as a partial wrist fusion
and proximal row carpectomy require a considerable amount
of therapy after cast removal. Total wrist fusion is the most reli-
able in terms of relieving pain and improving grip strength but
at the expense of wrist motion. Work restrictions after surgery
must be determined on an individual basis, taking into account
the specific job requirements. Maximum medical improvement
is anticipated 6 months postoperatively.
Thumb basilar joint
The basilar joint of the thumb consists of the metacarpal base
and trapezium bone.
2
Arthritis around the trapezium is the
second most common site for degenerative joint disease in the
hand (preceded only by the distal interphalangeal joint). More
frequent in females than males, the condition has been attrib-
uted to laxity of the important stabilizing ligaments of the thumb.
Patients with basilar thumb joint arthritis have pain localizing
to the base of the thenar muscles. Opening jars and turning
door knobs are often difficult tasks to perform comfortably.
As the condition advances, pinch and grip strength diminish,
and thumb range of motion may decrease as well.
Examination reveals a tender and enlarged basilar joint. Axial
grinding of the thumb metacarpal exacerbates the pain and may
elicit sensations of instability and crepitation. The Finkelstein
test is usually negative, helping to distinguish basilar joint arthri-
tis pain from de Quervain disease. The diagnosis is confirmed by
plain radiographs (Fig. 6d.10).
Initial treatment of basilar joint osteoarthritis includes
activity modifications, splint immobilization, nonsteroidal anti-
inflammatory medication, thenar muscle strengthening exer-
cises, and joint injection(s). If a patients symptoms are not
satisfactorily relieved by conservative means, surgical interven-
tion may be considered. The most commonly performed opera-
tion entails partial or total excision of the diseased trapezium
with stabilization of the thumb metacarpal base using local
tendon graft. A significant hyperextension deformity of the
thumb metacarpophalangeal joint may require a concomitant
procedure to stabilize the metacarpophalangeal joint. The post-
operative course typically involves a 4- to 6-week period of wrist
and thumb immobilization followed by a supervised therapy
program.
Pain relief from surgery is nearly universal but not always
complete, especially in younger and more active individuals.
Activity modifications in the workplace may be indicated for
an extended period of time after surgery. Thumb motion and
grip/pinch strength improve slowly. Maximum medical improve-
ment is anticipated after approximately 6 months.
Proximal interphalangeal joint
Osteoarthritis of the proximal interphalangeal joint is relatively
rare. The condition typically arises after a dislocation or intraartic-
ular fracture. The earliest signs of degenerative arthritis are swelling
and morning stiffness. Limited proximal interphalangeal joint
motion follows with the development of marginal osteophytes
(Bouchards nodes). Late joint degeneration leads to an angular
deformity and joint instability. Radiographs confirm the diagno-
sis and reveal the degree of joint deterioration.
Conservative treatment measures include nonsteroidal anti-
inflammatory medication, activity modifications, and short-term
splinting. Early in the degenerative process, steroid injections
can be helpful in ameliorating pain. If these measures fail and
considerable symptoms persist, surgical intervention may be
considered.
Arthrodesis is the most reliable method of eliminating
pain. Fusion of the ulnar digits at the proximal interphalangeal
joint level impairs grip strength and finger dexterity to a greater
Chapter 6d Osteoarthritis 245
Figure 6d.10 Thumb basilar joint arthritis (arrow).
degree than it does in the radial digits. Fusion rates vary from
84% to 100%. Implant arthroplasty also provides pain relief
with the added benefit of preserving partial joint motion. Joint
replacement, however, carries an attendant risk of implant break-
age and should be avoided in younger patients and/or manual
laborers. Maximum medical improvement is expected 3 to
6 months postoperatively.
Distal interphalangeal joint
Idiopathic degeneration of the distal interphalangeal joint
commonly involves multiple digits in a symmetric distribution,
whereas single finger joint degeneration is more suggestive of
previous injury. In most cases, symptoms are mild and functional
impairment is negligible.
Swelling and stiffness are common symptoms in early degen-
eration of the distal interphalangeal joint. As the disease progresses,
joint enlargement is seen secondary to osteophyte formation
(Heberdens nodes), resulting in limited motion. Late in the
disease, angular and rotational deformities occur at the finger
tip. Radiographs confirm the diagnosis and demonstrate the
severity of joint destruction.
In most individuals, conservative care is successful. Treatment
measures include nonsteroidal antiinflammatory medication,
activity modifications, corticosteroid injection(s), and splinting.
Surgery is reserved for symptomatic degenerative disease that
does not respond to conservative measures. Distal interphalangeal
joint fusion reliably relieves pain, restores stability and strength,
and improves the appearance of the digit. Fusion rates vary from
80% to 100%. Maximum medical improvement is expected 2 to
4 months postoperatively.
GANGLIA
Ganglia are fluid-filled structures that arise from a joint, tendon,
or tendon sheath.
28,30
They contain lubricating fluid called
mucin that is similar in content to but more viscous than the
fluid found in joints and tendon sheaths. Ganglia can emanate
from almost any anatomic region, but they are most common at
the wrist, the proximal margins of digital flexor tendon sheaths,
and the finger distal interphalangeal joints. Cysts communicate
with these structures through one or more ducts that account
for their intermittent fluctuation in size. The true etiology of a
ganglion is unknown, although approximately 10% have been
associated with previous trauma.
Carpal ganglia
Ganglia of the wrist are seen most frequently dorsally, near the
articulation of the scaphoid and lunate bones (Fig. 6d.11). They
occur less commonly at the palmar aspect of the wrist, adjacent
to the flexor carpi radialis tendon. Cysts may be multiloculated
and much larger than clinically apparent, extending far away
from their point of origin.
Patients with carpal ganglia may complain of activity-related
wrist pain and weakness. Guarding with minor loss of wrist
motion secondary to pain may result. In most cases, however,
the cysts yield few or no symptoms and require no specific inter-
vention. For a symptomatic dorsal wrist ganglion, aspiration of
the cyst with or without a corticosteroid injection is initially rec-
ommended and successful in up to 50% of cases. Aspiration is
relatively contraindicated for volar wrist ganglia because of the
close proximity of the radial artery. In these cases temporary
wrist splinting and use of a nonsteroidal antiinflammatory
medication may be helpful.
Surgical excision of wrist ganglia is indicated for persistent
pain, with reported recurrence rates averaging approximately
5%. The procedure is frequently performed in an open manner,
although an arthroscopic technique for excising dorsal ganglia
was recently described.
25
After ganglion excision, most patients
experience continued low-grade discomfort for several weeks.
Supervised therapy may be helpful in diminishing pain and
in restoring wrist motion and grip strength. Maximum medical
improvement is anticipated 2 to 3 months postoperatively.
Retinacular cysts
Ganglia arising from the digital flexor tendon sheath are termed
volar retinacular ganglia or retinacular cysts. Appearing as a small
bump at the base of a digit adjacent to the palmar digital flexion
crease, this type of cyst commonly causes discomfort during
activities that require gripping or holding objects in the palm.
A painful cyst can usually be treated by needle aspiration.
Surgery to excise the lesion is considered in recalcitrant cases and
when the diagnosis is uncertain. A rapid return to regular work
activities is expected.
Mucous cysts
Cysts arising from the distal interphalangeal joint, termed mucous
cysts, are invariably associated with degenerative arthritic changes
in the underlying joint. Because of their location, mucous cysts
Figure 6d.11 Wrist magnetic resonance image, axial view. Dorsal
ganglion attached to the scapholunate interval (arrow).
may disrupt the germinal matrix of the nail bed and lead to
longitudinal nail plate grooves and ridges.
Aspiration and instillation of a corticosteroid can be
attempted, but this treatment is rarely curative. Because the
distal interphalangeal joint is immediately deep to the skin
surface, aspiration increases the likelihood of septic arthritis.
Simple cyst excision carries a recurrence rate of 25% or greater.
Excision of the cyst in conjunction with debridement of mar-
ginal joint osteophytes, however, is successful in over 95% of
cases. Recovery after surgery is relatively rapid, and unrestricted
use of the hand should be possible within 6 weeks.
COMPLEX REGIONAL PAIN SYNDROME
Complex regional pain syndrome (CRPS) is a neurogenic dis-
order characterized by pain out of proportion to the level antic-
ipated with the diagnosis, swelling, autonomic dysfunction,
and joint stiffness.
1,32
In the past, a variety of terms, including
reflex sympathetic dystrophy, causalgia, Sudecks atrophy, and
shoulder-hand syndrome, has been used to describe this condi-
tion. Type 1 CRPS develops after a noxious event without iden-
tifiable nerve injury, whereas type 2 CRPS occurs in association
with a nerve injury.
The pathogenesis of CRPS remains poorly understood.
Autonomic hyperactivity is implicated in syndrome development,
and in many cases psychologic factors seem to play a role. Initially,
pain, swelling, restricted motion, and vasomotor changes (hyper-
hidrosis, erythema, excessive warmth) predominate the symptom
complex. After several months, swelling changes from a soft to a
hard brawny edema. Eventually, the skin appears shiny and glossy,
and stiffness becomes marked with fixed joint contractures.
The diagnosis of CRPS is made on clinical examination but
may be confirmed by a variety of objective tests. Radiographs
frequently reveal diffuse osteopenia secondary to bone dem-
ineralization. Three-phase bone scans show characteristic diffuse
uptake in the involved areas. Thermography can depict asym-
metric temperature when compared with the contralateral limb.
Anesthetic blockade at the neck/shoulder level confirms the
diagnosis in cases with primary involvement of the sympathetic
nervous system.
Successful treatment of CRPS depends on prompt diagnosis
and early intervention. The appearance and persistence of
inordinate pain after injury or surgery is typically the first sign. The
possibility of nerve injury should be entertained and any painful
stimulus (e.g., cast compression) eliminated. Active range-of-
motion exercises, edema control, interval splinting, and a stress-
loading program are initiated by an experienced therapist.
Pharmacologic treatment measures include corticosteroids, -
adrenergic blocking agents, calcium channel blockers, and regional
anesthetic injections. To address marked joint contractures late in
the disease process, surgical intervention may be indicated.
Evidence suggests that the earlier treatment is instituted, the
better the chance for a successful result. A significant percentage
of patients, however, still complain of pain, cold intolerance,
sensory disturbances, swelling, hand weakness, and stiffness years
later. Once the chronic stages of CRPS have occurred, results are
less favorable, with expected varying degrees of permanent upper
extremity impairment.
CONCLUSION
Management of an occupational-related disorder of the wrist or
hand is contingent upon the recognition of factors related to
condition development, a coordinated team approach to care,
and the patients active participation in recovery. Conservative
treatment measures include supervised therapy, splinting,
corticosteroid injection, oral pain medication, and activity modi-
fications. Surgical intervention may be indicated for trauma,
advanced nerve compression lesions, arterial thrombosis, recalci-
trant tendonitis, symptomatic degenerative arthritis, painful
ganglia, and various other conditions. The ultimate goals of treat-
ment should include patient satisfaction, symptom resolution,
and return to gainful employment.
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Biomechanical Aspects
of Hand Tools
Robert G. Radwin
The mechanical relationships between hands, tools, and tool
operation are important for understanding and controlling
physical stress of tool operators. Hand exertions needed for
many tool operations are affected directly by the selection of
specific tools and accessories for the task. Although many of
the recommendations in this chapter are based on years of exten-
sive biomechanics research, others arise out of simple mechani-
cal principles and reasonable assumptions about mechanical
relationships between tools and their operators. The objective is
to illustrate how the characteristics of a particular tool (such as
size, shape, output, and accessories) and its manner of use (such
as orientation or location relative to the operator) can signifi-
cantly affect the effort needed for performing specific tasks.
Both manual (hand powered) and power (electric, pneumatic,
or hydraulic) hand tools require that operators produce forces
at varying levels. Manual tools may require exertion of forces
to squeeze together tool handles, such as those of pliers and cut-
ting tools. Other manual tools may require twisting, pulling,
or pushing. Safe operation of a power tool requires that an
operator support it adequately in a particular position and apply
the necessary forces while reacting against the force generated
by the tool itself. Force demands that exceed an operators
strength capabilities can cause loss of control and result in an
accident or an injury. If improper selection, installation, or use
of a power tool requires an operator to make substantially greater
exertion than necessary, it may lead to muscle fatigue or a mus-
culoskeletal disorder.
1,5,28,39,40
Tools that are selected to minimize
hand forces are usually the best ones for the task.
The discussion begins with simple manually operated hand
tools, including screwdrivers and pliers. An investigation of
the means by which different kinds of screw fasteners can affect
forces in the hands is followed by a description of how selection
and installation of power hand tools can control the static and
dynamic hand forces associated with their use. Mathematical
and biomechanical calculations are provided to enable interested
readers to follow them and to impress other readers less concerned
with how objective conclusions can be ascertained through mostly
deterministic methods. These principles should be applicable to
occupational health professionals in the selection and installation
of tools. Designers and engineers should be able to adapt these
calculations to new tools and job designs.
MANUAL SCREWDRIVERS
One of the most commonly used hand tools, the screwdriver,
is available in various sizes and forms suitable for different types
C HA P T E R
6e
F
F
x
F
y
Direction
of twist
Direction
of rotation
L
Figure 6e.1 Rotation and perturbation of a manual screwdriver when
the handle is twisted in the hand.
of screws and work situations. A screw is tightened usually
by grasping the screwdriver handle and simultaneously applying
a torque while exerting a push force. The amount of torque,
T, needed for tightening a screw depends on the kind of screw
and the characteristics of the screw joint such as friction, screw
diameter, thread, and clamping load.
The push force is often called feed force. Feed force, F, is the axial
force applied against the screwdriver shaft that is required to thread
the screw and keep the screwdriver blade seated. Numerous task-
related factors affect feed force, including thread type (whether the
screw is self-tapping or threaded), material hardness, thread size,
and hole diameter. The choice of a particular size screwdriver can
have a great effect on the hand exertion required for a task.
Handle length
A question often asked is how does screwdriver length affect
hand force? Experience has found that a longer screwdriver
handle generally results in less effort.
32
This can be explained by
considering the motions needed for tightening a screw. When
a screw is tightened, torque is transferred to the handle, usually
by rotating the forearm in combination with flexion and ulnar
deviation of the wrist. The asymmetry of the hand, wrist, and
forearm relative to the screwdrivers radial axis produces
eccentric rotation of the handle that causes perturbation of
the handle and shaft along a horizontal displacement from the
vertical axis (Fig. 6e.1). The magnitude of this displacement
depends on the particular action and anthropometry of the wrist.
This perturbation causes the screwdriver shaft to tilt to a maximum
angle, , as the screwdriver rotates.
If screwdriver handle size, diameter, and shape and shaft
diameter remain the same, hand and wrist rotation is unaffected
by the shaft length, so the handle perturbation remains constant.
Assuming that the handle displaces the same distance from the
axis of the fastener shaft (Fig. 6e.1), the maximum angle, , that
the screwdriver shaft tilts as it is twisted can be described as
Orthogonal feed force components (Fig. 6e.1) can be resolved
into
F
y
F cos, F
x
F sin
If a screwdriver has a length, L, then the maximum component
parallel to the fastener shaft is F
y
:
Solving for F,
A consequence of this relationship is that if the required axial
force component F
y
remains constant, F decreases as L increases.
Hence, the hand force exerted can be reduced by increasing L
and using the longest screwdriver available. For example, if the
shaft of a 6-cm screwdriver displaces 3 cm, the feed force F
needed to drive a screw is
Therefore, the maximum feed force can be as much as 15%
greater than the axial force needed. If the screwdriver length is
increased to 25 cm, the feed force needed to drive a screw would be
which decreases the force feed to only as much as 1% more force
than is actually needed.
Of course, a very long screwdriver may not be practical under
all circumstances. Clearance and spatial constraints may limit
the size of screwdriver that can be used. Furthermore, a very
short screwdriver can facilitate the precision grip needed for light
precise work, such as that afforded with a jewelers screwdriver.
Another way to limit the horizontal perturbation of a screw-
driver as it rotates in the hand is by supporting the screwdriver
shaft, as might be done when two hands are used. If the screw-
driver were held straight by supporting the shaft with the fingers
of the free hand, then the tilt angle remains close to 0 degrees
and F
y
~
~
F cos 0 degrees ~
~
F. This action therefore aids the
operator by keeping the axial feed force requirements minimal
and unaffected by screwdriver length. When high feed forces
are required, screwdriver shafts should be long enough to be
pinched or gripped by the other hand as a guide. Using a similar
argument, the hand force needed for a nut driver should be
mostly independent of the shaft length because the shaft is
coupled to the nut, permitting concentric rotation with the
handle despite the asymmetries of the hand and forearm.
Handle diameter
Another common question is how does a screwdriver handle
diameter affect hand force? Several studies investigated the effect
of handle diameter on the torque capability of the hand. A study
involving volitional torque exerted for different manual screw-
drivers, locking pliers, and wrenches found that the resulting
torque magnitude was influenced strongly by the kind of tool
and the posture assumed.
26
From a purely mechanical standpoint,
a greater handle diameter should result in more torque at the screw-
driver shaft for the same effort, provided that the frictional prop-
erties of the handles are similar and the diameter is not too large.
The diameter of a screwdriver handle plays a critical role in
limiting a users torque-generating capability. Large grip forces
are often needed for sustaining a grip and for coupling the hand
and the tool to prevent the handle from slipping. A simplified
relationship between the torque and diameter illustrates the
effect of mechanical advantage on torque:
T S G F
G
G
where T is torque, S is the shear grip force, G is the handle radius,
is the coefficient of friction between the hand and the handle,
and F
G
is grip force.
32
If F
G
remained constant, torque would lin-
early increase as the handle diameter increased. As is well known,
however, grip strength is not constant for all diameters but
rather is affected by handle size.
4,17,19
If a handle is too large or
too small, the strength of the hand is greatly compromised. The
relationship between cylindrical handle size and grip strength is
summarized in Figure 6e.2.
29
Maximum grip force occurs
around 6 cm. Consequently, the optimal diameter is one in
which a further increase in diameter increases the mechanical
advantage while simultaneously decreasing grip force. Research
has found that this optimum depends on handle design, friction,
gender, and hand size.
32
Torque performance diminishes when
handle diameters are greater than 5 cm,
33
and a diameter of 4 cm
is sometimes recommended for screwdrivers.
7,8
Sufficient friction must be present between the handle and
the hand to provide a secure grip, exert force or torque,
and prevent a tool from slipping. Surfaces that do not provide
adequate friction require greater grip force that may result in
greater effort and even loss of control of the tool. The amount
of friction depends on the coefficient of friction between the
hand and the material or object grasped. Some materials have
greater coefficients of friction and consequently better frictional
characteristics than others.
No one handle size is practical for all tasks, and certain handles
serve some objectives better than others. A panel of ergonomics
experts recommends using a small-diameter handle (8-13 mm)
F
F
F
y
y
_
,
1
]
1

cos sin
.
1
3
25
1 01
F
F
F
y
y
_
,
1
]
1

cos sin
.
1
3
6
1 15
F
F
L
y
_
,
1
]
1
cos sin
1

F F F
L
y

_
,
1
]
1
cos cos sin

1

_
,
sin
1

L
Chapter 6e Biomechanical aspects of hand tools 250
for a precision grip and a large-diameter handle (50-60 mm) for
a power grip.
27
In one study, handles between 31 and 38 mm in
diameter were considered optimal for a power grip
12
; several
studies recommend 50 mm as an upper limit diameter.
4,33,38
SCREWDRIVER BLADES AND SCREW HEADS
Screwdriver feed force can be affected by the particular type of
screw fastener head and screw tip needed.
6
Self-tapping screws
require more feed force than do screws tightened through pre-
tapped holes. Material hardness and friction are also important
factors to consider for self-tapping screws. Feed force requirements
increase as the torque level increases for cross-recess screws.
Allowances should be made for all these factors. The three most
common threaded fastener heads are slotted, Phillips, and Torx
(Fig. 6e.3), each of which has different feed force requirements.
Slotted screws
The oldest and simplest type of screw head, the slotted screw, has
a single slot across the entire diameter of the head. When a screw-
driver blade is inserted inside a screw slot and rotated, contact is
usually made at the two edges of the blade, as shown in Figure 6e.4.
The size of the screwdriver width, w, limited by the radius of the
screw head provides a slight mechanical advantage for applying
torque against the screw. Wider screw heads and screwdriver blades
generally require less torque exertion at the screwdriver shaft.
We ignore frictional force by assuming that friction between
the screw and screwdriver blade is zero. (Because in this case,
friction assists the operator by helping keep the screwdriver
blade in the screw slot, zero friction would be the worst-case
condition.) If the width of the screwdriver blade is w and the
applied torque at the screwdriver shaft is T, then the normal
contact force, F
C
, between the blade and the screw head slot is
Because the blades of slotted screwdrivers are usually tapered
to an angle to ease insertion of the screwdriver blade and
accommodate different size screw slots, the normal contact force
F
C
is not actually perpendicular to the screwdriver shaft but
rather acts at an angle perpendicular to the blade edge (Fig. 6e.4).
This results in an axial force at each contact point
F F
T
W
y C
sin sin
F
T
W
C

Chapter 6e Screwdriver blades and screw heads 251
4 5 6 7
400
300
200
Handle span (cm)
G
r
i
p

s
t
r
e
n
g
t
h
Figure 6e.2 Grip strength for a population of 29 subjects (19 university
students and 10 factory workers). Error bars represent one standard
error of the mean.
Slotted Phillips head Torx
Figure 6e.3 Slotted head, Phillips head, and Torx
head screws.
that acts to push the screwdriver blade out of the slot as torque
is applied to the shaft. The hand must react against this force by
exerting an equal and opposite axial force F
y
that is a component
of the feed force. Because there are two contact points, the total
axial force is 2F
y
. Consequently, the axial force required to keep
the blade from coming out of the slot is
The greater the torque T, the greater the axial force needed to
keep the screwdriver blade in the slot. If the screwdriver blade
taper angle is 12 degrees,
If the screwdriver blade angle is not tapered but parallel to
the slot, this force is negligible (F
y
0) because no axial force acts
to unseat the blade. Such a screwdriver, however, would be limited
to certain size slots and more difficult to insert into them.
Phillips head screws
Although slotted screws are simpler, screwdriver blades some-
times slip out of slotted heads and have the potential to damage
or scratch the work piece. The Phillips head screw (Fig. 6e.3)
gained popularity because it prevented slippage and discour-
aged vandals from removing screws in public places with a coin
or knife edge.
31
A Phillips head screwdriver blade contains four wedges acting
on the blade. Similarly to the slotted screwdriver, the axial forces
acting parallel to the fastener can be described by the equation
Because is typically greater for Phillips head screws and w is
much smaller, F
y
is considerably more than for slotted screw-
drivers. The typical taper angle for a Phillips head screw is 40
degrees, so
which is more than six times the force needed for a slotted screw
with an equivalent diameter head.
Torx head screws
Torx screws offer the advantages of both slotted screws and Phillips
head screws. Because 0 for Torx head screws (Fig. 6e.3),
no axial force component other than the actual feed force is
required to advance the fastener. Because the screwdriver blade
cannot be tapered to accommodate different-size screws, Torx
head screws are not as flexible as slotted or Phillips head screws.
The disadvantage of requiring a large assortment of screwdrivers
with corresponding blade sizes may be outweighed by the
mechanical advantage of Torx head screws. Furthermore, they
are more difficult to tamper with because Torx head screwdrivers
are less readily available than slotted and Phillips head screw-
drivers and an assortment of sizes are needed. The advantages
and disadvantages of slotted, Phillips, and Torx head screws are
summarized in Table 6e.1.
PLIERS AND CUTTING TOOLS
The particular finger or combination of fingers used can affect
grip strength.
2,37
As the strongest fingers, the thumb, index, and
middle fingers should be used for producing the most grip force.
The weaker ring and small fingers should be used for stabiliz-
ing handles rather than acting as primary force contributors.
Sometimes tool operators handle tools in ways that take these
differences into account.
F
T
W
T
W
4 40 2 57 sin( ) . .
F F F
T
W
y C
4 4 4 sin sin .
F
T
W
T
W
2 12 0 42 sin( ) . .
F F
T
W
y
2 2 sin .
Table 6e.1 Summary of ergonomic advantages
and disadvantages of different screw heads
Screw
head Advantages Disadvantages
Slotted Very flexible toolone size fits all Difficult to keep seated in the
slot
Requires little axial feed force Can slip and damage work
piece
Phillips Easy to keep seated in head Requires more axial feed force
Flexible tool
Torx No axial feed force needed Inflexiblemust have a specific
Easy to keep seated in head size for an associated screw
head
F
y
F
c
F
c
W
T
Figure 6e.4 Static forces acting on a slotted screwdriver blade and shaft.
Offering the mechanical advantage provided from squeezing
together two opposing lever arms, pliers are used often for pinch-
ing, grasping, and cutting. The common use of pliers involves
a grip depicted in Figure 6e.5, where the pliers jaw is held on the
radial side of the hand. In many instances, however, this grip
does not optimize the mechanical advantage with finger strength
and can result in greater exertion than necessary.
Swedish researchers observed that some sheet metal workers
held metal shear blades on the ulnar side of the hand by using an
inverted grip (Fig. 6e.6) rather than that used with conventional
shears.
10,41
Finger strength data revealed that the inverted grip
allowed a greater span between the larger index finger and thumb
than between the small finger and the palm, providing
a better-suited handle size for more force in each cut.
14
The articulation angle from the closed position to the pivot
point is defined as . The jaw span X
j
is related to the grip
span X
i
as
where L
i
is the distance from the fulcrum to the finger i, L
j
is the distance from the fulcrum to the jaw tip, and X
i
is the
grip span available for finger i.
Assuming there are no coupling effects between fingers, the
resultant force is the sum of all four fingers. Individual-finger
normal strengths for the distal phalanx while grasping handles of
different sizes are taken from Amis.
2
By summing the moments
about the pivot point, the total moment is
M
J
F
1
L
1
+ F
2
L
2
+ F
3
L
3
+ F
4
L
4
This moment is counteracted by that produced from reaction
forces at the jaw. Consequently, the maximum jaw force is
Using the dimensions provided in Table 6e.2, the maximum
jaw force available increases from 714 to 786 N (10) just by
inverting the handle. Because the index and middle fingers have
the greatest strength, they are provided with larger moment
arms for generating force with the inverted grip, providing addi-
tional mechanical advantage. One study observed that the max-
imum force of one finger depended not only on its grip span but
also on those of the other fingers.
14
POWER HAND TOOLS
One of the best methods of controlling applied hand exertion is
to substitute a power hand tool for a manual tool. In fact, many
repetitive jobs could not be performed without the use of power
tools. Modern power hand tools can operate at high speeds and
produce very high forces. Exertions and forces acting against the
hand in power tool operation can be reduced by eliminating excess
weight, by making the best use of the mechanical advantage, or by
F
M
L
j
j
j
X X
L
L
i j
i
j
Chapter 6e Power hand tools 253

L
j
L
1
L
2
L
3
L
4
X
j
X
1
X
2
X
3
X
4
Figure 6e.5 Static forces acting on the hand when a pair of pliers is
grasped.
Figure 6e.6 Inverted pliers grip.
providing mechanical aids for holding tools, parts, and materials.
Selecting a power hand tool having certain dimensions and shapes
can often reduce tool reaction forces and provide mechanical
advantages that assist the operator. Increasing friction between the
hand and objects grasped can also reduce the forces required for
gripping tools.
Nut runners and power screwdrivers are widely used for
securing screws and threaded fasteners in manufacturing and
assembly operations, such as in the automotive, mechanical
equipment, and electronics industries. Using electromyography
as an index of muscle effort during pneumatic shut-off nut-
runner operation, Radwin et al
37
observed that electromyographic
activity during threaded fastener torque buildup was affected by
tool torque output and torque buildup time. Electromyographic
activity during torque buildup was more than three times greater
than during preparation and shut-off.
Oh and Radwin
29
observed that the operator initially overcomes
the tool reaction force with a concentric muscle exertion. As the
force rapidly rises, the tool eventually overcomes the operator,
causing the motion in opposition to muscle contraction and
resulting in an eccentric muscle exertion. Due to passive prop-
erties of the muscle, during an eccentric, or lengthening, con-
traction the muscle acts like a spring, producing proportionally
more force as it lengthens.
Because they directly affect handle force in a complex man-
ner, tool geometry, mass, moment of inertia, and center of grav-
ity are important factors in the design and selection of power
hand tools. By providing mechanical advantages, the handle
length of pistol-grip and right-angle tools and the diameter of
in-line tool handles likewise affect hand exertions.
11,20,36
Tool
load affects grip force,
9,16,21,43
fatigue onset,
18
task performance,
13
and subjective preference by tool operators.
3,30,42
In addition
to the static forces exerted by an operator when carrying and
positioning tools or when a tool is running at a constant state,
the impulsive forces and torques produced by rotating spindle
power hand tools are dynamic.
Static forces
Lin et al
22
developed a mechanical model of power hand nut-
runner operation for static equilibrium (no movement) con-
ditions. Using hand force, reaction force from the work piece, tool
weight, and tool torque, the static force model calculates handle
force when carrying tools and when spindle torque is constant.
The model uses a Cartesian coordinate system relative to the
orientation of the handle grasped using a power grip (Fig. 6e.7A).
This coordinate system has the x-axis perpendicular to the axial
direction of the handle, the y-axis passed through the long axis
of the handle, and the z-axis perpendicular to both. The origin is
the end of the bit or socket.
Hand forces are described here in relation to these coordinate
axes. To simplify the model, we assume that orthogonal forces
can be summed along the handle without producing coupling
moments, an assumption that allows force to have a single point
of application. The variables used in the model are summarized
in Table 6e.3 and illustrated in Figure 6e.7.
When a tool is in static equilibrium, the sums of all forces (F),
moments (M) about the origin, and grip moments generated by
the spindle (M
G
) are zero. Therefore three vector equations can
be developed:
F
i
+ R
i
+ W + F
F
+ F
s
0 ( F 0)
( F
i
+ R
i
) L
i
+ W L
G
0 ( M 0)
S
i
G
i
+ T 0 ( M
G
0)
These vector equations can be written in matrix form:
The full model considers forces and moments exerted by
both hands (subscripts 1 and 2), but not all these equations are
S
i
G
i
L
GY
L
1Y
T
Figure 6e.7 Forces acting in the hand when an in-line nut runner is
operated.
Table 6e.2 Pliers handle dimensions and associated
finger strength for showing the mechanical advantage
using an inverted grip
Grip Index Middle Ring Small Total
Conventional
Grip span X
i
(cm) 6.0 6.6 6.4 5.4
Grip strength F
i
(N) 60 63 44 37 204
Finger distance L
i
(cm) 7.0 8.3 10.2 11.4
Torque (Nm) 420 523 449 422 1814
Jaw force F
J
165 206 177 166 714
Inverted
Grip span X
i
(cm) 5.4 6.4 6.6 6.0
Grip strength F
i
(N) 62 64 43 35 204
Finger distance L
i
(cm) 11.4 10.7 8.3 7.0
Torque (Nm) 707 685 357 245 1994
Jaw force F
J
278 270 141 97 786
1 0 0 1 0 0 0 0 0 0 0 0 1 0 0
0 1 0 0 1 0 0 0 0 0 0 0 0 1 0
0 0 1 0 0 1 0 0 0 0 0 0 0 00 1
0 0 0 0 0 0 0 0 0 0 0
0 0
1 1 2 2
1 1 2 2
L L L L
L L L L
z y z y
z x z

xx
y x y x L L L L
G
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0
1 1 2 2
11 2
1 2
1
0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
x x
y y
z
G
G G
G 00 0 0 0 0 2
1
1
G
F
F
z
x
1
]
1
1
1
1
1
1
1
1
1
1
1
1
yy
z
x
y
z
x
y
z
x
y
z
sx
sy
sz
F
F
F
F
S
S
S
S
S
S
F
F
F
1
2
2
2
1
1
1
2
2
2
1
]
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
11
1
1
1

W R R F
W R R F
W R
x x x Fx
y y y Fy
z z
1 2
1 2
1
+ +
R F
L R L R L R L R L W
z Fz
z y y z z y y z Gz y
2
1 1 1 1 2 2 2 2 LL W
L R L R L R L R L W L
Gy z
x z z x x z z x Gx z Gz 1 1 1 1 2 2 2 2 + + WW
L R L R L R L R L W L W
x
y x x y y x x y Gy x Gx y 1 1 1 1 2 2 2 2 + +
TT
T
T
x
y
z
1
]
1
1
1
1
1
1
1
1
1
1
1
1
.
required for all situations, and in certain cases the equations
system may be reduced depending on tool shape and operating
conditions. For example, the shear force needed for in-line tools
is insignificant for pistol grip tools except when a hand grasps the
tool around the spindle. The tool torque and feed force are
assumed always to act in a single axis. When the matrix becomes
degenerate or singular, additional assumptions are needed to
solve for handle force.
Nut runners are commonly configured as pistol grip, right
angle, and in-line (Fig. 6e.7). Examples are provided in this
article to demonstrate the resulting matrix reduction for these
three common tool shapes. A set of more general cases are fully
described in Lin et al.
22
Pistol-grip power drivers
Consider the free-body diagram of the pistol-grip nut runner in
Figure 6e.7B, which shows the use of the right hand (subscript 1),
and the tool geometry shown in Figure 6e.8A. The spindle stall
torque T acts clockwise in the xy-plane. The tool operator
must oppose this equal and opposite reaction torque T
z
counter-
clockwise by producing a reaction force R
1x
along the x-axis that
is equal to and opposite of the hand force component F
1x
.
This is not, however, the only force that the tool operator
must produce. A force acting along the z-axis F
1z
provides feed
force F
FZ
and produces an equal and opposite reaction force F
Sz
.
The operator must also react against the tool mass to support
and position the tool by producing a vertical force component
F
1y
. The tool weight W
y
and push force F
1z
tend to produce a
clockwise rotation of the power tool about the spindle in the
yz-plane that is countered by this vertical support force.
Table 6e.3 Legend of variable notation
Variable* Description
F
i
Handle force acting on hand i
S
i
Shear force acting in hand i, applied when the handle rotates
in the y-axis
R
i
Reaction force produced by the spindle torque at point i
W Tool weight
F
F
Feed force; not applicable when carrying a tool
F
s
Surface support force; not applicable when carrying a tool
T Tool torque
L
i
Location vector of point i
L
G
Location vector of the center of gravity
G
i
Grip radius at point i, applied when the handle rotates in
the y-axis
*All the variables in bold type are vectors. Subscript i represents a specific hand used in
operating the tool. The right hand is annotated using subscript 1 and the left hand is
annotated using subscript 2.
In the case of one-handed operation, the right hand (subscript 1)
reacts against all tool forces and torques. The vector equations
can therefore be reduced to
These equations reveal several relationships between tool
parameters and hand force. Torque reaction force R
1
x F
1
x
is directly proportional to the reaction torque T
z
and inversely
proportional to the handle length L
1y
. The torque reaction force
is therefore less for longer tool handles than for shorter handles.
The vertical support force F
1y
is inversely proportional to the
tool length L
1z
and dependent on tool weight, center of gravity
location, handle length L
1y
, and feed force F
F
F
1z
. The equa-
tions indicate that less effort is probably needed for supporting
a pistol-grip power hand tool when the tool body is long than
when it is short. When feed force is large, supporting force
decreases when the handle length is short.
This is why handles aligned close to the tool spindle axis and
with long tool bodies are advantageous for tools such as power
hand drills. These drills often require considerable feed force
with torque reaction forces relatively less than for a nut runner,
so a short handle is favorable. Alternatively, when torque is large
and feed force is small, a tool with a long handle is advantageous.
When both feed force and torque are significant factors, how-
ever, as when drilling large holes or shooting self-tapping screws
in hard wood, these parameters must be optimized.
The model can be used for comparing resultant hand forces
associated with different tools for the same operation and for
selecting the tool requiring the least exertion. Consider the
four hypothetical power nut runners shown in Figure 6e.9.
All four tools weigh the same (30 N) and have the same torque
output with different dimensions and mass distribution.
Comparisons between the four tool dimensions are provided in
Table 6e.4.
Assuming one-handed operation, resultant hand force was
predicted by using the model for the four different tools and
plotted as a function of torque in Figure 6e.9. Hand force
was determined for both low-feed force (1 N) and high-feed
force (100 N) conditions when the tools were operated against a
vertical surface. When feed force was small, the resultant hand
force was affected mostly by the torque reaction force, which
increased as torque increased for all four tools. Because the
greatest force component in this case was the torque reaction
force, tools 3 and 4 resulted in the least resultant hand force
because they had the longest handles (Table 6e.4). Tool 3,
however, had a considerably greater resultant hand force when
feed force was high because the hand was located farthest
from the spindle for that tool. This effect was not observed
for tool 4, which also had a long handle, because of its greater
tool body length. Although tool 4 had the least resultant hand
force when both feed force and torque levels were high, tools 1
and 2 had less resultant hand force for high feed force and
low torque because these tools permitted the hands to grasp the
tool close to the spindle axis. Consequently, the best tool
depended on both feed force and the torque requirements for
the task.
All tools were assumed to weigh the same; had they varied
weights, the differences might have been even greater. Additional
factors the model can consider include relative tool weight, mass
distribution, and tool orientation. This analysis does not take
into account the relative strength capabilities of the hand in the
three component directions, although use of such a model does
not exclude strength comparisons.
0 0 1 0 1
0 1 0 1 0
0 0 0 0 1
0 0 0
0 0 0 0
1
1
1
L
L
L
z
y
y
1
]
1
11
1
1
1
1
1
]
1
1
1
1
1
1
F
F
F
F
F
W
x
y
z
sy
sz
y
1
1
1
0
1
]
1
1
1
1
1
1
F
W L
T
Fz
y Gz
z
.
L
1z
L
Gz
T
z
T
z
F
Fz
L
Gy
W
y
F
1z
F
1x
F
1y
L
1y
y
x
z
Figure 6e.8 Static forces during pistol-grip nut runner operation.
The reaction force transmitted to the hand for right-angle
power drivers is affected also by the magnitude of spindle torque
and the tool dimensions. Right-angle nut runner spindle torque
can range from less than 0.8 Nm to more than 700 Nm. A tool
operator opposes these forces while supporting the tool and main-
taining control. This torque is transmitted to the operator as a
reaction force and opposed by the great mechanical advantage
resulting from the long reaction arm created by the tool handle.
37
Right-angle power drivers
A right-angle nut runner is functionally nothing more than a
pistol-grip nut runner with a very short body and long handle.
The model for a right-angle nut runner is shown in Figure 6e.7C.
Because right-angle nut runners are usually operated with both
hands, two-hand forces are now in the z-axis; F
1z
is applied at the
handle for supporting the tool, and F
2z
is applied over the tool
spindle to help provide feed force. (When these tools are used
one handed, the equations for a pistol grip nut runner apply.)
Right-angle tools have short spindles perpendicular to the
long axes of the handles. Because the handle is usually longer
than the spindle, these tools are often held in two hands
(Fig. 6e.7C). In this case, the right hand (subscript 1) grasps the
tool at the distal end of the tool handle, whereas the left hand
(subscript 2) grasps it proximal to the spindle. It is further
assumed that equal amounts of force are exerted by both hands
to react against tool torque along the long axis of the handle, and
hence F
1z
F
2z
. The resulting matrix is
These equations can be used to compare hand forces between
a right-angle and a pistol-grip power nut runner used on a
horizontal surface (Fig. 6e.10). The right-angle nut runner in this
example weighs 20 N, whereas the pistol-grip nut runner weighs
50 N. A graph of torque reaction force plotted against torque
shows that the mechanical advantage of the right-angle nut
runner for high torque levels is considerable. The other hand,
however, exerts greater feed force for the right-angle nut runner
than for the pistol-grip nut runner. Because the pistol-grip nut
runner weighs more and has its center of gravity closer to the
tool spindle, it requires less support force for F
1z
and F
2z
than for
the right-angle nut runner (Fig. 6e.10). Sometimes handle force
can be reduced further through the proper use of accessory
handles and torque reaction arms.
In-line power drivers
The form factor and associated forces and moments involved
in operating an in-line power tool are shown in Figure 6e.7D
and dimensions in Figure 6e.8C. Assuming that the right
hand (subscript 1) supports the tool, the static handle force
matrix is
The static torque developed at an in-line power hand tool
spindle has an equal and opposite reaction torque T
y
that must
be overcome by tangential shear forces between the hand and
the handle. The tangential shear force S
1y
produces torque about
the grip radius G. The shear force S
1y
is proportional to the com-
pressive hand force F
G
and the coefficient of friction between
the hand and the handle, similar to a manual screwdriver except
in this case the spindle rather than the hand is producing the
torque. In-line power driver operation is therefore limited by the
1 0
0 1
1
1 G
F
S
W
T x
y
y
y
y
1
]
1

1
]
1

1
]
1
1 0 1 0
0 1 0 1
0 0
0 0
1 2
1 2
1
1
1
]
1
1
1
1
L L
L L
F
F
y y
y y
x
zz
x
z
x
x
x Gy
F
F
W
T
W L
2
2
0
1
]
1
1
1
1
1
]
1
11
1
1
1 2 3 4
Tool types
Figure 6e.9 Comparison of resultant hand forces acting on the hand for four equivalent power nut runners plotted against reaction torque.
Table 6e.4 Pistol-grip nut runner dimensions, load,
and center of gravity location
Tool Weight (N) L
1z
(m) L
1y
(m) L
1z
(m)
1 30 0.09 0.06 0.07
2 30 0.40 0.09 0.26
3 30 0.11 0.50 0.07
4 30 0.40 0.50 0.32
maximum compressive grip force an operator can produce and
by the dimensions of the tool. The relationship between the
static torque, grip force, and tool diameter is similar to that of
manual screwdriver operation:
T
y
S
1y
G F
G
G
Push-to-start activated power hand tools free the operator
from having to squeeze a trigger or lever, but they can increase
force requirements because they require more feed force to start
them. A flange at the end of in-line handles helps prevent the
hand from slipping during feed force exertion.
15
Accessory handles and torque reaction arms
Accessory handles assist a pistol-grip power tool operator by
providing an additional handle for two-handed operation.
A torque reaction bar can sometimes be used to transfer loads
back to the work piece. In fact, reaction torque can be com-
pletely eliminated from the operators hand by use of either a
stationary reaction bar adapted to a specific operation so that
reaction force can be absorbed by a convenient solid object or
a torque-absorbing suspension system.
A reaction bar can be installed on in-line, pistol-grip, and
angled tools. The advantages of tool-mounted reaction devices
are that (1) all reaction forces are removed from the operator;
(2) one-hand-operated pistol-grip and in-line reaction bar tools
can be used rather than right-angle nut runners, which usually
require two hands; (3) reaction bar tools can be less restricting on
the operators posture; (4) tool speed and weight are improved
over right-angle nut runners in most tool sizes; and (5) use of
reaction bars can improve tool performance.
The limitations are that (1) torque reaction bars must be
custom-made for each operation, (2) several attachments can
make tool use difficult, (3) adding weight to the tool makes it
more cumbersome to handle, and (4) the intervention is not
practical when the accessibility is limited, the manipulation is
restricted, or the reaction bar has no surfaces to contact. If a reac-
tion bar is provided, however, a smaller tool handle can be used.
When an accessory handle or torque reaction bar is used
with a pistol-grip nut runner (Fig. 6e.11), the horizontal hand
force F
1x
is reduced. If a vertical force is applied to a torque
reaction bar, as depicted in Figure 6e.12, an additional term is
needed for the sum of the moments in the z-axis:
T F
1x
L
1y
+ F
Sy
L
Sx
0
As a result, F
1x
becomes
If a torque reaction bar is used and all the torque reaction
force acts against a stationary object, then
T F
Sy
L
Sx
Consequently,
F
1x
0
F F L
T
L
S S 1
1
x y x
+
y
x
y
z
L
1y
L
Gy
L
zy
L
1z L
Gz
W
z
F
Rz
F
2z
F
1z
F
1x
T
z
T
z
Figure 6e.10 Static forces for right-angle nut runner operation.
Tool counterbalancers
The force requirements for a job are often related to the weight
of the tools being handled. The effort needed for holding an
object in the hands is usually associated with its mass,
34,35
so that
heavier tools generally require greater exertion. There is a trade-
off between the selection of a lightweight tool and the benefit
of the added weight for performing operations that require
high feed force. A spring counterbalance or air balancer can help
reduce the load from heavy tools that are operated frequently.
When used to support the tool, the counterbalance produces
a force that opposes gravitational force. This is illustrated with a
pistol-grip power tool in Figure 6e.13. When the tool is held
freely in the hand, there is no torque to react against (T 0)
and consequently no reaction force (F
1x
0). Besides creating a
moment in the yz-plane, the counterbalance force F
Cy
also influ-
ences F
1y
. The moment is counteracted by a coupling moment,
C, from the hand, as described in the following equations:
F
1y
+ W
y
+ F
Cy
0
F
1y
L
1z
+ W
y
L
Gz
+ F
Cy
L
Cz
+ C 0
If the counterbalance force F
Cy
is set to counteract the tool
weight W
y
, then
F
Cy
W
Ty
Consequently, the y-axis component of the hand force
becomes F
1y
0. The location that the counterbalance force acts
against the tool can affect operator exertion when holding it.
Solving for the coupling moment C,
C F
Cy
(L
Gz
L
Cz
)
The equation shows that the coupling moment can be
eliminated (C 0), if
L
Gz
L
Cz
Balancers should therefore be attached to tools at or near
their centers of gravity so as to avoid additional effort by the tool
operator to counteract the handle moment.
Balancers should be installed carefully so that minimal effort
is needed when holding and using the tools in the desired
work location. Spring counterbalances produce a force that
opposes gravitational force so the tool weight is reduced. If
installed incorrectly, however, these balancers can actually
have the reverse effect of increasing force. Spring tension should
be adjusted so that the operator does not have to counter more
force than necessary and balancers so that the tool aligns as
close to the work area as possible to prevent unnecessary reach-
ing. The counterbalance should not lift the tool when it is
released so that the operator must elevate the shoulder to
reach it; the tool should remain suspended at the same height at
Right angle Pistol grip
Tool types
Figure 6e.11 Comparison of hand forces between a right-angle nut runner and a pistol-grip nut runner operated on a horizontal surface.
L
Sx
T
Z
F
Sy
F
1x
Figure 6e.12 Force and moment arm for a pistol-grip nut runner
equipped with a torque reaction bar.
which it was released. Also, situations where operators tend to
work ahead of or behind the assembly line should be avoided.
If a tool is moved horizontally, a trolley and rail system should
be installed. Special attention may be required to be sure that
the balancer is attached directly above the work.
Dynamic forces
Tool torque buildup model
There are three elements involved in power nut runner operation
using a threaded fastener: the operator, the tool, and the mechan-
ical joint that joins or clamps two objects together, the hardness
of which is analogous to the stiffness of a spring. The clamping
force of a threaded fastener is therefore proportional to torque,
with a desired clamping force achieved by rotating the fastener
to a specific target torque. Levels of joint stiffness range from
a hard joint (30 degrees of spindle rotation) to a soft joint
(360 degrees of spindle rotation). Examples are illustrated in
Figure 6e.14
The spindle torque and angular displacement during torque
buildup have a linear relationship such that
where T is tool spindle torque, is spindle angular displacement,
T
t
is the target torque, T
0
is the rundown torque, and
t
is the
target angle.

( ) ( ) T
T T
T T
t
t

0
0
L
1y
L
Cz
L
1z
L
Gz
F
Cy
L
Gy
W
y
F
1y
C
x
y
z
Figure 6e.13 Static forces when
handling a pistol-grip power hand tool
with a counterbalance. Counterbalance
force F
Cy
creates a moment in the
yz-plane that is counteracted by a
coupling moment C.
Figure 6e.14 Recording of torque
buildup profiles for hard (light line)
and medium-soft (heavy line) joints.
(From Lin JH, Radwin RG, Fronczak FJ,
Richard TG: Ergonomics 46(12):
1161-1177, 2003.)
Pneumatic motors have a distinctive speed-torque relationship.
The motor does not produce torque at the free running speed,
whereas it exerts maximum torque when the motor stalls.
The spindle speed can be described using the equation
where S is spindle speed expressed as a function of torque T,
T
max
is the motor maximum torque output, and S
0
is free run-
ning speed.
Because speed S(T) is the derivative of angular displacement
(T), the unique solution for the differential equation is the
torque delivered to the spindle
The force experienced by the hand can be obtained by
dividing the equation for T(t) by the distance of the hand from
the rotating spindle.
Handle force model: dynamics
Lindqvist
25
proposed that a simple mass-spring mechanical
system might be sufficient to describe the handle response to
impulsive reaction forces encountered in nut runner operation
but did not identify specific parameters for these elements.
Lin et al
23
advanced this model of the human operator; their
method identifies these mechanical properties to predict the
kinematic and kinetic response of the handle (motion and force)
when an impulsive reaction force was encountered in threaded
fastener power hand tool operation. A brief description of the
model is provided here.
The human operator is represented as a dynamic mechanical
analog of a single degree-of-freedom mechanical system consist-
ing of a linear spring, a mass, and a viscous damper (Fig. 6e.15).
Instead of modeling for individual contributing muscles, the
model combines the loading of the muscles and joints into
mechanical elements without considering the directions of the
loads. The mechanical properties, M
s
, k
s
, and c
s
, are assumed to
be passive and invariant for an individual, a given posture, and
a tool orientation. The effective mass M
s
represents the total
contributions of the standing operator coupled to the tool
through the hands. The effective spring stiffness and damping
represent the gross effect of the operator acting against the han-
dle, including contributions from the entire body and nonspe-
cific muscle groups. A system identification method using free
oscillation measures these mechanical parameters for various
work locations for three common tool shapes: pistol grip, right
angle, and in-line. This method measures the influence of the
operators mechanical elements on the system dynamic response
(oscillation frequency and damping ratio) of a known mechani-
cal system. The mechanical parameters are then extracted
analytically.
23
Given the mechanical parameters for an operator, the
model estimates the dynamic response (angular displacement
and force) when the operator encounters an impulsive reaction
force from a power tool. A torsional dynamic equilibrium
equation about the tool spindle axis can be written. The
following differential equation results in terms of the tool
rotation :
where T(t) is the tool torque, M
s
, c
s
, and k
s
are the operator
mechanical parameters, J
T
is the mass moment of inertia of the
tool about its spindle, and h is the distance between the hand
and the tool spindle.
( ) J M h
d
dt
d
dt
T
s + + +
2
2

2
c h k h T(t) s
2
s
2
T t T T T e
T T S
T
t
t
t
( ) ( ) max max
( )
max
+ +

0
0 0
S T S
T
T
( ) ( ),
max

0
1
Figure 6e.15 A pistol-grip pneumatic hand tool is illustrated with a
normal operator grip. The mechanical parameters can be defined as
follows: M
s
the total effective mass of the operators arm, hand, and
a portion of the upper body lumped at the distance h from the center
of rotation of the tool spindle or line of action of the tool torque, T(t).
J
T
the rotational mass moment of inertia of the tool about the center
of mass of the tool. h location of the center of pressure of the
operators hand on the tool handle. k
s
the effective stiffness of the
operators arm, hand, and a portion of the upper body. c
s
the
effective damping of the operators arm, hand, and a portion of the
upper body. T(t) the tool torque which is transmitted to the operator in
a typical mechanical fastening operation. the rotation of the tool
and hand about the tool spindle axis. H horizontal distance between
the floor and the handgrip. V vertical distance between the ankles
and the handgrip. (From Lin JH, Radwin RG, Richard TG: Handle
dynamics predictions for selected power hand tool applications.
Hum Fact 45(4):645-656, 2003.)
This second-order differential equation can be solved numer-
ically using finite difference techniques and a discrete time step
variation of the tool torque, T(t). The result will be a description
of the time variation of the tool rotation, (t),
i
s s M h J
t
c h
t
M
T
+
+
+
1
2
2
2
1
2
2
( )
(

ss
s i
s s h J
t
k h
c h
t
M h
T
2
2
2
2
2
2 +
+
)
( )
(
22
2
1
+
1
]
1
1
J
t
T
T
i
i
)
( )
,

where i is the iteration step, t is the time step, and T is the tool
torque.
With the rotational response of the tool predicted, the
motion of the handle can be defined as h(t). The force F(t)
delivered to the handle can be approximated by
Here the handle force F was estimated by solving the above
equation. The tool operator mechanical model was also used to
estimate tool handle kinematics during torque buildup. The
resultant handle displacement and force for using a right-angle
tool having buildup times ranging from 35 (hard) to 1000 (soft)
ms was calculated and is plotted in Figure 6e.16 for the female
with the smallest stiffness and the male with the greatest stiffness.
24
CONCLUSIONS AND RECOMMENDATIONS
Tool operator exertion can be minimized by considering the
forces acting on the tools and the way they are used for a specific
task. The selection of alternative hand tools for different work
c h k h F(t) s s
d
dt
+
The following recommendations can be made:
1. When large feed forces are necessary, use the longest manual
screwdriver available and provide a screwdriver shaft long
enough so that it can be gripped by the other hand as a guide.
Nut drivers and socket drivers also help reduce hand forces by
providing concentric handle rotation and additional mechanical
advantage at the screw head.
2. Large-diameter manual screwdriver handles with high frictional
characteristics are recommended; if the handle diameter is too
large, however, the mechanical advantage may be counteracted
by reduced grip strength.
3. Phillips head screws should be avoided because they require
greater axial push force as torque increases. Torx head
screws provide the least axial reaction force.
4. Pliers and shears can sometimes be used to a greater mechan-
ical advantage by gripping them so that the pivot is on the
ulnar rather than the radial side of the hand.
5. Torque reaction force is less for longer pistol-grip and right-
angle nut runners than for equivalent tools with shorter han-
dles.
6. When pistol-grip power hand tools that have longer tool
bodies are used, less vertical support force is required than for
Figure 6e.16 Model prediction for handle displacement and force when using a right-angle nut runner on a horizontal surface for different torque
buildup times. (From Lin JH, Radwin RG, Richard TG: Handle dynamics predictions for selected power hand tool applications. Hum Fact 45(4):
645-656, 2003.)
situations can be assisted by comparing the mechanical rela-
tionships between the task and tool parameters. Other aspects
that should be considered but are not covered in this chapter
include repetitive use, assumed postures, vibration exposure,
and contact stress.
equivalent tools with shorter tool bodies, provided that their
mass distribution is similar.
7. All other factors being equivalent, when feed force is large
and torque is small, a pistol-grip power tool with a shorter
handle should be used. When feed force is small and torque
is large, a pistol grip power hand tool with a longer handle is
more advantageous.
8. Torque reaction bars help eliminate torque reaction forces,
and accessory handles help distribute torque reaction forces
among the two hands.
9. A tool counterbalance can help reduce the force needed to
support a power hand tool. The optimal location for attaching
a balancer is at the tool center of gravity.
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C HA P T E R
Hip and Knee
7
Epidemiology of the
Lower Extremity
Gunnar B. J. Andersson
Musculoskeletal impairments increase with age. This is true for
lower extremity impairments as well. Praemer et al
26
concluded,
based on 1995 data, that over 5% of the U.S. population had
lower extremity or hip impairments. This number is probably
slightly higher today as the population has aged. Although the
percentile rates were 1.8% among those below age 17, it was 7.7%
in individuals 65 years of age and older. Women experience a
slightly smaller percentage of lower extremity impairments than
men. More than 20 million Americans have osteoarthritis (OA),
which makes OA the leading cause of long-term disability in per-
sons older than age 65 years. Nonspecific knee pain is reported
by 4.6% of persons older than 18 years, and the corresponding
number for hip pain is 3.1% (NHANES III). Specific to the work-
place, in 1996 there were about 5.7 million occupational injuries
in the United States, of which 6.4% were fractures and 43.6% were
sprains and strains. Some 8.6% of fractures and 10.3% of sprains
and strains involved the leg (excluding the foot and ankle); 71% of
injuries occur from knee causes: overexertion (28%), contact with
objects (26.2%), and falls (16.9%). Fractures resulting in work loss
often involved the lower extremities (41.8%), but most of those
affect the foot and ankle. On the other hand, sprains and strains
involved the lower extremity frequently (20%), with the knee
being affected in 8.5% of cases (Table 7a.1).
In a population-based study of 55 year olds (575 subjects),
Bergenudd
5
showed that 11% had femoropatellar pain and 10%
had knee joint pain. The prevalence was higher in women than
in men. In a study correlating knee pain and low IQ measured
40 years earlier, low job satisfaction, obesity, and increased s-glu-
tamyltransferase were found in men, whereas low education
level, low income, low life success, and sleeping disturbances
were found in women. For the entire group, knee pain and high
occupational workload were also correlated. Similar results were
found for hip pain. Occupational workload correlated with hip
pain in men but not in women. Increased body weight correlated
with knee pain in men and hip pain in women.
As with many other musculoskeletal conditions, the back-
ground for symptoms from the knee and hip is multifactorial.
Table 7a.1 Occupational injuries of the lower
extremities as a percentage of all injuries:
U.S. data.
25
Diagnosis Hip Knee Lower leg Multiple
Fracture 0.3 2.6 2.0 1.2
Sprain and strain 0.3 7.9 0.3 0.8
C HA P T E R
7a
Age, sex, and social life are of importance, along with occupa-
tional factors. When compared with the upper extremities, neck,
and lower back, diseases and disorders of the lower extremities
have less association to work.
12
Workers compensation claims
for disorders of the lower extremities account for fewer than 10%
of all musculoskeletal claims in Sweden.
DEFINITIONS
From an etiologic perspective, occupational musculoskeletal dis-
orders can be viewed as caused, aggravated, or accelerated by
work. An occupational injury is defined as any injury that results
from a work-related accident or exposure involving a sudden
event in the work environment.
25
An occupational illness is any
abnormal condition or disorder other than that resulting from
occupational injury that is caused by exposure to factors associ-
ated with employment.
25
Cumulative trauma disorders are con-
sidered occupational illnesses.
OCCUPATIONAL INJURIES
In the United States, injuries to the musculoskeletal system in
1997 had an annual incidence of 7.1 per 100 full-time equivalent
workers. Injuries among men are most common between 18 and
44 years of age.
Rupture of tendons and muscles is not often caused by occu-
pational loading. The strength of tissues decreases with age, but
ruptures are most often seen in sports activities and as a result of
rather high-loading injuries.
OCCUPATIONAL ILLNESS
Joints are made for loading and movement. The cartilage of the
joints is well designed to withstand compression, translation, and
shear forces. Deleterious types of loading are loads in extreme
positions (nutcracker effect) and axial impact loads particularly at
high speed.
23
Low-frequency vibrational loading may be deleteri-
ous to the joints and the joint cartilage but is often attenuated by
the time it reaches the knee and hip. High-frequency vibration is
unlikely to affect the lower extremities. Highly repetitive, monot-
onous work can cause a variety of problems in the joints, bones,
tendons, and peripheral nerves. These types of loading condi-
tions are not often seen in the lower extremities in relation to
occupation but can occur during sports activities.
Tendinitis
Tendinitis, tenosynovitis, myalgia, and other conditions of mus-
cles and tendons are uncommon in the lower extremities.
Bursitis
Eighteen bursae surround the hip joint, and approximately 10
surround the knee joint. Specific diagnoses are often difficult
to make. Bursitis caused by sports overuse is not uncommon, but
bursitis around the hip as an occupational illness is rarely seen.
Bursitis of the knee, especially prepatellar or infrapatellar, is often
seen in jobs that require kneeling, for example, floor layers, fish-
ermen, and plumbers.
28-30
Nerve entrapments
Only occasionally is nerve entrapment seen in the lower extrem-
ities. Ischial neuralgia, or wallet sciatica, a sensation along the
ischial nerve caused by compression at the infrapiriforme fora-
men, may be encountered by sitting, particularly when having a
well-filled wallet in the back pocket. Peroneal nerve compression
at the side of the knee may cause palsy and can result from work
activities. This may happen to tractor drivers during prolonged
sitting in a twisted position and from accidents. Ilioinguinal neu-
ralgia and lateral cutaneous nerve neuralgia are reported as occu-
pational illnesses. The mechanism is often some type of pressure
over the anterior part of the iliac crest from heavy belts or other
equipment, especially if loaded with tools or other weights.
Edema, tiredness, and dull pain in the legs are more common in
those with static sitting or standing occupations than in those
who work in a more varied posture.
37
Compartment syndromes
are rarely due to occupational loading of the lower extremities.
This syndrome is more often seen as a result of sports activities
and as a complication of fractures and other traumatic injuries.
Rheumatic diseases
Arthritis and rheumatism account for 66% of the musculoskeletal
conditions among women and 51% among men. Osteoporosis
accounts for an additional 11% of musculoskeletal disease, occur-
ring predominantly in females.
25
Rheumatic diseases are not
caused by occupational loading but may be worsened by it.
Osteoarthritis
The prevalence of OA is greater in women than in men. Physical
examination more often results in a diagnosis of OA, as compared
with radiographic examination, when narrowing of the joint
space is used as the criterion. If osteophytosis is included as a
sign of OA, the prevalence is much higher. Around 12% of the
U.S. population have OA in any joint.
8,12,18
Table 7a.2 shows the
prevalence of OA diagnosed by radiographic examination in dif-
ferent age groups.
18,25
Diagnosis by examination revealed more
OA than diagnosis by history. The explanation is that many indi-
viduals are symptom free.
In the NHANES I study,
2
the prevalence of OA of the knee
was 2.3% to 18% in those aged 45 to 74 years, with a larger pre-
valence in the elderly and in women. Hip OA was found in
0.2% to 6.6% in those aged 25 to 74 years, more in the elderly
but with less sex difference than OA in the knee. OA of the hip
and knee has been studied in relation to occupational and other
factors. These results were confirmed in recent studies.
1,6
Secondary OA is due to previous known trauma (e.g., frac-
ture, surgery) or disease (e.g., hip dysplasia, osteochondritis,
Perthes disease). Primary OA has been shown to have a multifac-
torial background. Bilateral hip and knee OA has been suggested
to have an etiology different from that of unilateral OA.
Hochberg
13
reported on a group of 1337 students who graduated
from The Johns Hopkins University School of Medicine from
1948 through 1964. The cumulative incident of knee OA at age
65 was 6.3%, whereas hip OA existed in 2.9% of individuals.
Cumulative knee OA relative rise was three times higher in those
with a history of knee injury (13.9% vs. 6%). The incidence of
knee OA was 7.5 per 1000 person-years among those with a knee
injury compared with 1.2 per 1000 person-years, for a relative
risk (RR) of 5.2. Similarly for the hip, the incidence was 3.2 per
1000 person-years among those with hip injury compared with
0.7 without a hip injury (RR, 3.5). The increased risk remained
significant even after adjustment for age, sex, body mass index,
and physical activity at study entry. Clearly, lower leg injuries
should be prevented to reduce the risk of knee and hip OA.
Heredity
Most OA is not attributable to single genes. Rather, common
OA appears to result from interactions between multiple genes
and the environment. In a comparative population study in San
Francisco, standardized rates of primary hip OA, expressed as
numbers per 100,000 population per year, were 1.5 in Japanese,
1.5 in Chinese, 1.6 in Filipinos, 5.1 in Hispanics, 8.3 in blacks,
and 29.4 in whites. The hereditary factor often results in a more
generalized OA in different locations of the body.
22
The percentage of hip OA, defined as lowered height of the
joint cartilage, at 70 years of age in Sweden is about 2% in both
sexes. Knee OA has a prevalence of 2% in men and 3% in women
at 70 years of age in Sweden. However, a relation to occupational
loading or sports is more clearly shown in men, whereas obesity
correlates more with knee OA in women. Consequently, a hered-
itary factor increasing the risk for females to contract OA of the
knee is likely.
22
Obesity correlates with symptomatic OA in the
hip
31
and also in the knee, which is clearly shown in females, and
has an RR of about 4.
10,22
Hip OA
Sports Lindberg and Montgomery
20
found a 2.8% prevalence
of hip OA in control subjects as compared with 5.6% in athletes
Chapter 7a Epidemiology of the lower extremity 270
Table 7a.2 Prevalence of osteoarthritis as
diagnosed by history or examination by gender
and age group: rate per 100 persons
Diagnosis Diagnosis by
by history examination
Age Males Females Males Females
Less than 20 years
2039 years 0.2 0.4 0.2
4059 years 3.4 8.4 4.0 8.9
Over 60 years 17.0 29.6 20.3 40.8
All ages 1.9 4.0 2.2 5.0
All ages over 20 years 4.5 7.3 4.2 9.0
and 14% in elite athletes (soccer players). Similar results have
been shown by Klunder et al.
16
Among those undergoing a total
hip procedure because of OA, Vingrd et al
32-34
found an RR of
4.5 for athletes. Those athletes who also had a physically
demanding job had an RR of 8.5. Different results have been
shown in studies of long-distance runners.
9
Occupation Vingrd et al
32-36
found more symptoms caused by
hip OA in men exposed to greater physically demanding jobs.
Farmers, construction workers, firefighters, and food processing
workers had significantly more OA than expected (RR, 2.4). For
those exposed to both occupational loading and sports activities
the RR was 8.5, and for sports alone the RR was 4.5. In this
study, being overweight had an RR of 2.5. Disability pension for
hip OA was more often received by those with high occupational
load exposure than by those with low exposure (RR, 12.4).
33
The risk occupations were construction workers, metal workers,
farmers, and forestry workers. An increased risk for hip OA has
been shown in farmers, with RRs of 9.7 to 12 in several
studies.
4,7,11,15,19,27
In female farmers, no difference from control
subjects was found.
4
Knee OA
Sports A Swedish study
22
found a knee OA prevalence of 7% in
soccer players as compared with 1.6% in control subjects. The
prevalence was higher in those with known meniscal tears or
anterior cruciate ligament ruptures.
Occupation The Framingham study showed an odds ratio of
2.2 for OA of the knee in jobs requiring knee bending and at
least a medium level of physical activity.
10
The etiologic fraction
or attributable proportion of knee OA to occupational physical
loading was 15%. Obesity accounted for 10%. Only a few females
had physically demanding jobs in the study, and no gender asso-
ciation was found.
10
In the NHANES study, knee OA was
increased among men and women with physically demanding
jobs: odds ratios of 1.88 in women (not significant) and 3.13 in
men of younger ages, and odds ratios of 3.49 and 2.45, respectively,
at higher ages. The occupational etiologic fraction was estimated to
be 32%.
2
Dock workers have been shown to have more knee OA than
office workers.
24
Lindberg and Montgomery
20
found an increas-
ing risk for knee OA in shipyard workers as compared with office
workers and teachers. Vingrd et al
32-34,36
found an increased risk
for knee OA among farmers, construction workers, and firefighters.
That study also showed an increased risk of knee OA symptoms
in female janitors and letter carriers. Therefore, a moderately
increased risk of symptom-giving knee OA has been shown in
physically demanding occupations.
4,17,21
Overweight and some
sports activities seem to increase the risk of symptom-giving knee
OA more than any occupation.
A consensus discussion in 1992 in Malm on the etiology of
OA concluded that unfavorable weight bearing and repeated
minor trauma may contribute to OA.
22
This is in agreement with
the current etiologic hypotheses. Static load, repeated trauma
over long periods, and an unnatural use of joints are likely to con-
tribute to OA. Regarding occupation, farmers, professional ballet
dancers,
3
and professional soccer players have a much higher fre-
quency of OA than expected and are therefore considered to
carry an increased risk for OA. Other physically demanding jobs
have less of an increase in RR for OA, around 2 to 3, similar to
the RR for obesity and lower than the increased risk in some elite
athletes.
22
REFERENCES
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knee pain among older Americans: results from the Third National Health and
Nutrition Examination Survey. J Am Geriatric Soc 47(12):1435-1438, 1999.
2. Andersson JJ, Felson DT: Factors associated with osteoarthritis of the knee in the first
National Health and Nutrition Examination Survey (NHANES I): evidence for an asso-
ciation with overweight, race, and physical demands of work. Am J Epidemiol
128(179):89, 1988.
3. Andersson S, Nilsson B, Hessel T, et al: Degenerative joint disease in ballet dancers.
Clin Orthop 238:233-236, 1989.
4. Axmacher B, Lindberg H: Coxarthrosis in farmers. Clin Orthop 287:82-86, 1993.
5. Bergenudd H: Talent, occupation, and locomotor discomfort. Doctoral thesis. Malm,
Sweden, 1989, Lund University.
6. Christmas C, Crespo CJ, Franckowiak SC, Bathon JM, Bartlett SJ, Andersen RE: How
common is hip pain in older adults? Results from the Third National Health and
Nutrition Examination Survey. J Fam Pract 51(4):345-348, 2002.
7. Croft P, Coggon D, Cruddas M, Cooper C: Osteoarthritis of the hip: an occupational
disease in farmers. BMJ 304:1269-1272, 1992.
8. Cunningham LS, Kelsey JL: Epidemiology of musculoskeletal impairments and asso-
ciated disability. Am J Public Health 74:574-579, 1984.
9. Ernst E: Jogging-for a healthy heart and worn out hips? J Intern Med 228:295-297,
1990.
10. Felson DT, Hannan MT, Naimark A, et al: Occupational physical demands, knee
bending and knee osteoarthritis: results from the Framingham study. J Rheumatol
18:1587-1592, 1991.
11. Forsberg K, Nilsson B: Coxarthritis on the island of Gotland. Increased prevalence in
a rural population. Acta Orthop Scand 63:1-3, 1992.
12. Hadler NM: Occupational musculoskeletal disorders. New York, 1993, Raven
Press.
13. Hochberg MC: Prevention of lower limb osteoarthritis: Data from the John Hopkins
Precursor Study. In VC Hascall, KE Kuettner, eds: The many faces of osteoarthritis.
Berlin, 2002, Birkuauser.
14. Hult L: The Monkfors investigation. Acta Orthop Scand Suppl 16:1-76, 1954.
15. Jacobsson B, Daln N, Tjrnstrand B: Coxarthrosis and labour. Int Orthop
11:311-313, 1987.
16. Klunder KB, Rud B, Hansen J: Osteoarthritis of the hip and knee joint in retired
football players. Acta Orthop Scand 51:925-927, 1980.
17. Kohatsu N, Schurman D: Risk factors for the development of osteoarthritis of the
knee. Clin Orthop 261:242-246, 1990.
18. Lawrence RC, Hochberg MC, Kelsey JL, et al: Estimates of selected arthritic and
musculoskeletal diseases in the U.S. J Rheumatol 16(4):427-441, 1989.
19. Lindberg H, Axmacher B: Coxarthrosis in farmers. Acta Orthop Scand 59:607, 1988.
20. Lindberg H, Montgomery F: Heavy labor and the occurrence of gonarthrosis.
Clin Orthop 214:235-236, 1987.
21. Nicolaisen T: Health among postmen. Copenhagen, 1983, General Directorate for
Post and Telegraph (in Danish).
22. Nilsson BE: The Tore Nilson Symposium on the etiology of degenerative joint disease.
Acta Orthop Scand Suppl 64(253): 54-61, 1993.
23. Nordin M, Frankel VH: Basic biomechanics of the musculoskeletal system, ed 2.
Philadelphia, 1989, Lea & Febiger.
24. Partridge REH, Dulthie JJR: Rheumatism in dockers and civil servants. Ann Rheum
Dis 27:559-568, 1968.
25. Praemer A, Furner S, Rice DP: Musculoskeletal conditions in the United States.
Park Ridge, IL, 1992, AAOS.
26. Praemer A, Furner S, Rice DP. Musculoskeletal conditions in the United States.
Rosemont, IL, 1999, American Academy of Orthopedic Surgeons, pp. 1-182.
27. Thelin A: Hip joint arthrosis: an occupational disorder among farmers. Am J Ind Med
18:339-343, 1990.
28. Trner M: Musculoskeletal stress in fishery: causes, effects, and preventive
measures. Doctoral thesis. Sweden, 1991, University of Gteborg.
29. Trner M, Zetterberg C, Anden U, Hansson T, Lindell V: Workload and musculoskeletal
problems: a comparison between welders and office clerks. Ergonomics
34:1179-1196, 1991.
30. Trner M, Zetterberg C, Hansson T, Lindell V, Kadefors, R: Musculoskeletal symptoms
and signs and isometric strength among fishermen. Ergonomics 33:1155-1170,
1990.
31. Vingrd E: Overweight predisposes to coxarthrosis. Body mass studied in 239 males
with hip arthroplasty. Acta Orthop Scand 62:106-109, 1991.
32. Vingrd E: Work, sports, overweight and osteoarthrosis of the hip. Arbete och Hlsa
25, doctoral thesis, 1991, Karolinska Institute, Stockholm, Sweden.
33. Vingrd E, Alfredsson L, Fellenius E, Hogstedt C: Disability pensions due to
musculoskeletal disorders among men in heavy occupations. Scand J Soc Med
20:31-36, 1992.
34. Vingrd E, Alfredsson L, Goldie I, Hogstedt C: Sports and osteoarthrosis of the hip.
Am J Sports Med 21(2):195-200, 1993.
35. Vingrd E, Alfredsson L, Hogstedt C, Goldie I: kad risk fr arthros i knn och hfter
fr arbetare i yrken med hg belastning p benen. Lkartidningen 87:4413-4416,
1990.
36. Vingrd E, Hogstedt C, Alfredsson L, Fellenius E, Goldie I, Koster M: Coxarthrosis and
physical work load. Scand J Work Environ Health 17:104-109, 1991.
37. Winkel J: On fast swelling during prolonged sedentary work and the significance of
leg activity. Arbete och Hlsa, doctoral thesis, Stockholm, 1985, National Institute of
Occupational Health.
Chapter 7a Epidemiology of the lower extremity 272
Biomechanics of the
Hip and the Knee
Ali Sheikhzadeh
Biomechanical analysis of the hip and knee joints during daily
activities that occur in the home and work environment can
identify tasks that are potentially harmful for a healthy and an
injured joint. A kinematics and kinetic profile of uninjured joints
provides an understanding of joint contribution during func-
tional tasks, provides a baseline to identify abnormalities, and
thereby assists with diagnosis and treatment. Moreover, it facili-
tates the design and performance of reconstructive surgery and
rehabilitation programs.
The kinematics and kinetics of the hip and knee joints and
the joint forces that occur during activities of daily living are the
focus of this chapter. The application of biomechanical models
for calculating external forces and moments at the hip and knee
joints is explained first. The application of biomechanical con-
cepts in reducing joint forces and thereby risk of injury is then
discussed. The activities discussed are mainly physical activities
of daily living and those commonly performed at work such as
gait, stair climbing, rising from a chair, and lifting weights.
KINEMATICS OF THE HIP AND KNEE
A three-dimensional measurement of relative motion among
adjacent limb segments, comprehensive kinematics analysis is
expressed by 6 degrees of freedom, generally three translational
and three rotational angles. However, kinetics analysis involves
both static and dynamic analysis of internal and external forces
and moments acting on a joint. In the musculoskeletal system,
external forces frequently include the ground reaction forces, the
weight of the limb segment, and the force of one segment on
another. Muscle contractions, passive soft tissue stretch, and
articular reaction forces generate primarily internal forces.
Kinematics of the knee
The knee joint is composed of the tibiofemoral joint and the
patellofemoral joint. The tibiofemoral joint has the greatest
motion in the sagittal plane, 0 to approximately 140 degrees.
Provided by articulations between large convex femoral condyles
and smaller or nearly flat tibia condyles, this large range allows
extensive knee motion in the sagittal plane for the activities such
as walking, running, squatting, and climbing.
The knee motion in the transverse plane (internal and external
rotation) and in the frontal plane (abduction and adduction) is
affected by the amount of joint flexion. The interlocking of the
Table 7b.1 The mean of the left knee joint angle
performed by 20 normal elderly subjects during
11 functional activities
Function Mean
Level walking 64.5
Ascend slope 61.6
Descend slope 69.0
Ascend stairs 80.3
Descend stairs 77.8
Sit down low chair 92.5
Sit to stand low chair 95.0
Sit down standard chair 91.0
Sit to stand standard chair 89.8
Into bath 123.3
Out of bath 131.3
Rowe PJ, Myles CM, Walker C, Nutton R. Gait Posture 12:143-155, 2000.
femoral condyles in the knee in extension precludes almost any
motion in the frontal and transverse planes. The knee motion in the
transverse plane increases as the knee is flexed toward 90 degrees,
with a maximum of approximately 45 degrees in internal rotation
and 30 degrees in external rotation, and then decreases primarily
due to the soft tissue restrictions. Similarly, motion in the frontal
plane increases as the knee is flexed toward 30 degrees, reaching a
maximum of only a few degrees of abduction and adduction, and
then decreases as the knee flexion goes beyond 30 degrees.
Values for the average range of motion of the knee joint in
the sagittal plane during 11 common activities are reported in
Table 7b.1. A range of motion of 130 degrees is required for com-
mon daily living activities. Excluding the range of motion
required to bathe, 110
61
to 117 degrees
51
of knee flexion would
seem a reasonable goal for the rehabilitation of its motion for the
general population. The inability of the knee to move within the
range of motion required for daily living activities would be
compensated for by increasing the motion of other joints
51
or
avoiding trying to perform the task.
Kinematics of the hip
The hip joint is a synovial ball-and-socket joint with articulation
between the large nearly spherical head of the femur and the
acetabulum of the pelvis. With its inferior anterolateral and infe-
rior opening, the acetabulum provides a wide range of motion.
The concave acetabulum covers about two thirds of a spherical
femur head. As the hip joint is loaded, the acetabulum deforms
about the femoral head. The unloaded acetabulum has a smaller
diameter than that of the femoral head.
21
Hip motion takes place in all three planes, with the greatest
motion in the sagittal plane. The extreme motion of the hip joint
is limited by passive tension of the surrounding ligaments
and muscles (Table 7b.2). Passive hip flexion is approximately
140 degrees, whereas active hip flexion with the knee flexed is
125 degrees and with it extended is 90 degrees. Passive hip extension
is approximately 30 degrees, whereas active extension is 20 degrees.
59
C HA P T E R
7b
The hip abduction range is about 30 degrees, and adduction range
is about 25 degrees. The external and internal rotations of the hip
are 90 and 70 degrees, respectively, when the joint is flexed. The
internal and external rotations of the hip, when it is extended, are
approximately 15 and 35 degrees, respectively.
59
Most common daily activities require flexion, abduction, and
external rotation. The mean of motion during selected daily
activities is shown in Table 7b.3. Most daily activities require more
than 100 degrees of hip flexion.
30
Squatting and shoe tying with
the foot across the opposite thigh require the greatest motion in
the frontal and transverse planes. Walking on a level surface
requires about 30 degrees of flexion and 10 degrees of extension,
with minimal abduction-adduction and internal-external rotation.
Approximately 80 to 104 degrees of flexion and extension,
respectively, is required to sit on or rise from a chair.
The range of motion during daily activities should be inter-
preted cautiously. The reported range has been shown to be influ-
enced by age,
23
speed of movement,
15
and environmental task
constraints such as chair
46
and stair height. Mulholland and Wyss
44
demonstrated the significance of cultural sensitivity in the interpre-
tation of daily activities. In many parts of Asia and the Middle East,
a chair is not commonly used at home or work, and sitting on the
floor without support, sitting cross-legged, or kneeling are more
common than in Western countries.
22,44
Mulholland and Wyss
44
suggested that even rural as opposed to urban life-styles in differ-
ent geographic locations might demand significantly different ana-
lytical approaches and should be considered in evaluations of daily
physical activities. The current related literature on daily living
activities, including data reported in Tables 7b.1 and 7b.3, reflects
mainly the Western life-style and would not apply to the actual
life-styles of many people in Asian and Middle Eastern cultures.
There is a growing need for culturally and racially sensitive data
that allow for individual variation in the normal range of motion.
KINETICS OF THE HIP AND KNEE
Generally, a biomechanical model attempts to represent a simpli-
fied version of a complex task. Often these representations may
require gross oversimplification of forces and coincide with the
theoretical assumption of the model itself. However, the reliabil-
ity and validity of biomechanical models depend on realistic
assumptions and representations of the mechanical system and
accuracy of the experimental data that constitute the inputs
and/or outputs. In addition, an important aspect of developing
a model is to decide what should be included or neglected.
Although it is not always possible, generally the simplest model
that provides a valid representation of reality should be used.
Chapter 7b Biomechanics of the hip and the knee 274
Table 7b.2 Magnitude of hip range of motion and associated limiting ligaments and muscular tissues
Hip motion Magnitude of hip motion Examples of tissues that may limit the extremes of motion
Flexion 80 (with knee extended) Hamstrings and gracilis muscles
120 (with knee fully flexed) Inferior fibers of ischiofemoral ligament
Inferior capsule
Extension 20 of extension (with knee extended)* Predominantly iliofemoral ligament and anterior capsule; some components of the pubofemoral
and ischiofemoral ligaments
0 (with knee fully flexed) Rectus femoris muscle
Abduction 40 Pubofemoral ligament, inferior capsule, adductor and hamstring muscles
Adduction 25 Superior fibers and ischiofemoral ligament, iliotibial band, and abductor muscles such as
the tensor fasciae latae
Internal Rotation 35 Ischiofemoral ligament external rotator muscles (e.g., piriformis)
Extrenal Rotation 45 Lateral fasciculus of iliofemoral ligament, iliotibial band, and internal rotator muscles
(e.g., gluteus minimus, tensor fasciae latae)
*Implies 20 of extension beyond the neutral zero degree position.
From Neumann, DA: Kinesiology of the musculoskeletal system: foundations for physical rehabilitation. St. Louis, 2002, Mosby; p. 400.
Table 7b.3 Mean values for maximum hip range
of motion measured in three planes during several
common activities for 33 healthy men
Johnston RC, Smidt GL: Hip motion measurement for selected activities of daily living,
Clin Orthop 72:205-215, 1970.
The formulation of a comprehensive dynamic model of the
knee and hip joints is challenging because of the complexity of
internal forces acting on the joints and the difficulty of measur-
ing anatomic parameters precisely. For instance, a comprehensive
model of the hip joint should include the line-of-action of mus-
cles crossing it with respect to its axes of rotation in the sagittal
and frontal plane, as presented in Figure 7b.1. In addition to
the line-of-action of muscles, such a model should consider the
dynamic changes of these parameters during joint motion. The fol-
lowing methods are used to overcome the difficulty and complex-
ity of estimating the internal joint forces during dynamic tasks.
Analytical joint models
Often, even the simplest model of external forces generated by
gravity acting on the body provides crucial functional and clini-
cal information about a joint. As illustrated in Figure 7b.2, for
instance, a simplified free-body diagram of the lower extremity
during a single leg stand phase of stair climbing presents a rea-
sonable estimate of the tibiofemoral joint forces and patella tendon
force. The flexion moment of the lower leg is the product of the body
weight (BW) and its lever arm, the perpendicular distance of the
BW to the center of the tibiofemoral joint motion. The sensitivity
of the knee flexion moment to the carrying of objects during
occupational tasks can be determined by adding the weight of an
object to the external weights acting on the body.
Despite the oversimplification of the joint forces that may be
estimated based on a free-body diagram, a two-dimensional static
model can be used to analyze occupational tasks or to design
rehabilitation training. Typically, a person with arthritis pain or
patellofemoral joint pain is advised to avoid large forces created
by the quadriceps.
12
Figure 7b.3 illustrates the magnitude of the
external forces on the knee during two physical tasks requiring
knee extension, tibial-on-femoral knee extension (the line
between D and B) verses the femoral-on-tibial knee extension
during the 0 to 90-degree joint angle (the line between A and C).
During tibial-on-femoral knee extension, the external moment
arm of the weight of the lower leg increases from 90 degrees to 0 of
knee flexion. In contrast, during femoral-on-tibial knee exten-
sion, the external moment arm of the upper BW decreases from
90 degrees to 0 of knee flexion.
A more realistic biomechanical model of the knee should
include a better representation of the patellofemoral stresses and
forces within the quadriceps muscle. The single line of quadri-
ceps force in Figure 7b.2 should be replaced by four lines. The
four heads of the quadriceps muscle consist of distinct fibers that
Chapter 7b Kinetics of the Hip and Knee 275
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5.0 0.0 -5.0 (cm)
Figure 7b.1 A side view of the femoral head with the line-of-action of
several muscles crossing the hip in the sagittal plane. (From Neumann DA:
Kinesiology of the musculoskeletal system: foundations for physical
rehabilitation. St. Louis, 2002, Mosby, p. 400.)
Figure 7b.2 Free-body diagram of moments acting around the
center of motion of the tibiofemoral joint during stair climbing. The
ground reaction force (W) and its lever arm (a) are counterbalanced
by moments produced by the quadriceps muscle force through the
patellar tendon (P) and its lever arm (b). (From Nordin M, Frankel VH:
Biomechanics of the knee. In M Nordin, VH Frankel, eds: Basic
biomechanics of the musculoskeletal system. New York, 2001,
Lippincott Williams & Wilkins, pp. 176-201.)
Force P
b
a
Force W
M = 0
W a P b 0
W a = P b
P = W a
b
approach the patella at different angles, especially the vastus medi-
alis fibers, which approach from two distinct directions. The more
distal oblique fibers approach the patella at 50 to 55 degrees, and
the remaining more longitudinal fibers approach it at 15 to
18 degrees, both medial to the quadriceps tendon.
49
Cohen et al
12
presented a more comprehensive model of the knee joint, com-
puter simulated with geometric and anatomic details, to compare
the patellofemoral stresses and quadriceps force during open (with
0, 25-N, and 100-N load at ankle) and closed kinetic chain leg
exercises in the flexion range of 20 to 90 degrees. As demonstrated
in Figure 7b.4, the quadriceps muscle force and the average
patellofemoral contact forces increase progressively from 20 to
90 degrees.
To achieve a more realistic estimate of joint forces, a biome-
chanical model of the hip and knee joint should include the soft
tissues forces such as agonist-antagonist muscle forces in three-
dimensional dynamic environments. The exclusion of agonist-
antagonist muscle forces underestimates the internal joint forces.
However, the inclusion of these forces adds another layer of
complexity to the model and demands more advanced analytical
methods to solve indeterminate systems. Generally, inverse
dynamic models
47
or optimization methods
4,56
are used to solve
the indeterminate problem of determining muscle and contact
forces. For example, with the large number of muscles crossing
the hip (Fig. 7b.1) and with at least 27 separate musculotendinous
units crossing the joint, a unique demonstration of individual
muscle force can be achieved only by oversimplification.
Todays advances in computer science and technology provide
the possibility of creating virtual human reality.
10
The virtual
human concept aims at understanding human activities through
the simulation of accurate physiologic and anatomic models and
data. This type of simulation combines biomechanical models of
joints and mechanical properties of connective tissues to visualize
Figure 7b.3 The relative external torque generated by body weight acting on the knee joint between 90-degree flexion and full extension
(0 degree) during two styles of knee extension: (1) during femoral-on-tibial extension (A to C line), the external moment arm of the weight of the
lower leg increases from 90-degree knee flexion to full knee extension, and (2) during tibial-on-femoral extension (D to B line), the external moment
arm of the upper-body weight decreases from 90 degrees to 0 knee flexion. (From Neumann DA: Kinesiology of the musculoskeletal system:
foundations for physical rehabilitation. St. Louis, 2002, Mosby, p. 458.)
External Torque-Angle Plot
Relative
external torque
(% maximum)
100%
70%
0%
D
A
B
C
45 70 90 20 0
Knee angle (degrees)
EXTENSION
Figure 7b.4 Quadriceps muscle force exertion simulation based on
anatomical data from five cadavers for closed kinetic chain (CKC) and
open kinetic chain (OKC) exercises for knee flexion range of 20 to
90 degrees. The three OKC loading simulated conditions are OKC 0N,
knee extension with no load; OKC 25N, leg extension with 25-N external
force at the ankle; OKC 100N, leg extension with 100-N external force at
the ankle. (From Cohen ZA, Roglic H, Grelsamer RP, et al: Patellofemoral
stresses during open and closed kinetic chain exercises: an analysis
using computer simulation. Am J Sports Med 29:480-487, 2001.)
the results in both static and animated forms. For surgical implan-
tation of a proximal femur/hip prosthesis, for example, graphic
information about implants that is available directly from the
manufacturers or CAD/CAM files can be added to real images of
the patients anatomic parameters taken from computed tomo-
graphies. It can also be incorporated into the biomechanical
models of joints and soft tissues in functional tasks. For surgical
and medical education and for device development applications,
it is worthwhile to incorporate adaptive anatomic models, which
include prosthetic implants and fracture fixation devices. Advanced
computation environments for static posture, kinematics, kinetics,
and stress analysis under physiologic boundary and loading con-
ditions can be incorporated.
In vivo direct measurement of joint forces
Although biomechanical models deal with indirect estimates of
internal forces, the real-time continuous signal from an instru-
mented telemetric prosthesis has been used for direct measure-
ment of internal forces acting on the distal or proximal femur
during daily activities such as walking and stair climbing.
69
Direct
measurement of the hip contact forces was first obtained by
Rydell.
62
The peak hip forces during gait vary from 1.8 to 4.3
times the BW, with peak pressure occurring during heel strike
and early midstance.
4
These hip forces are related to the ground
reaction forces acting on the superior anterior acetabulum. For
patients measured at 11-31 months postoperatively, the average
hip forces during fast walking and climbing stairs was about
250% BW and slightly less than going downstairs.
7
Taylor and Walker
69
studied two patients over 2.5 years dur-
ing various daily activities. The average peak distal femoral shaft
forces for one patient during various activities were jogging
3.6 BW, stair descending 3.1 BW, walking 2.8 BW, treadmill
walking 2.75 BW, and stair ascending 2.8 BW. Bending moments
about the mediolateral axis (flexion-extension) and anteroposte-
rior axis (varus-valgus) peaked in the range of 4.7-7.6 BW cm
and 8.5-9.8 BW cm, respectively, over the follow-up period.
During similar activities, however, forces and moments for the
second subject were generally 45-70% less than those for the first
subject due to inadequate musculature around the knee.
69
The joint forces and moments of patients who have had joint
arthroplasty are expected to return to the values of healthy indi-
viduals within approximately 6 months after surgery.
2
The discrep-
ancy between forces and moments reported by various authors,
for example, Bergmann et al
7
and Taylor and colleagues,
69,70
reflect
the variation among individuals, success of surgery, location of
measured forces, and time of study with respect to surgery. For
example, Taylor and Walker offer a good estimate of the loading
conditions (distal femoral) acting at the knee and are assumed to
offer data different from what Bergmann and colleagues found
with respect to hip arthroplasty surgery.
In comparison with biomechanical models, direct measure-
ment produces valid data on internal forces. The information
serves mostly as validation
9,39,65
for biomechanical models and
provides useful insight into wear, strength, and fixation stability.
Direct measurement is otherwise difficult because of technologic
restrictions and ethical considerations, and because of a variety
of practical reasons only a limited number of subjects can be
studied.
69
Because the validity of collected information depends
on the extent to which joint mechanics and surrounding tissues
have been altered, generalizations cannot be made.
REDUCING INTERNAL JOINT LOAD:
APPLICATION OF BIOMECHANICAL
CONCEPTS
Determining the consequence of daily physical activities of work
and leisure on lower extremity joints is difficult because of the
complexities of structural anatomy and dynamic movements
combined with the calculation of internal and external forces act-
ing on joints. Musculoskeletal loading is influenced by a number
of individual differences such as age, weight, and gender; the activ-
ity itself; and the variables of the task. Such factors help explain
individual variation in functional abilities, biomechanical con-
sequences of physical performance on internal tissues, and poten-
tial risk or mechanism of injury. Biomechanical analysis of
physical activities such as walking, running, and stair climbing
provides understanding of internal and external forces acting on
a joint and their significance for injury and pain. Biomechanical
analysis of task variables such as stair or chair height influence
and gait speed demonstrate the degree to which selected charac-
teristics of a task may influence the physical demands of execut-
ing it and its consequences for joints and surrounding tissues. The
following is a brief description of selected variables that directly
or indirectly influence physical ability and musculoskeletal load-
ing during daily living activities.
Individual factors
Individual factors such age, gender, anatomic variation, and
medical history and disease stage are known directly or indirectly
to influence ability, internal resources for executing a task, and
distribution of internal forces and tissue tolerance. Except for
weight, individual factors cannot be controlled or altered, but
understanding a mechanism by which these factors may influ-
ence joint loading is important to explain injury mechanism, pre-
vent injury risk, and design rehabilitation programs for special
groups of individuals.
Age, weight, and gender
Individual factors such as age,
1,15,16,21,34,58
weight,
1,11
and gender
35,36,67
influence the internal joint forces and ultimately the injury
mechanism and risk. Biomechanical properties of soft tissues and
the hip and knee joints are known to be different between gen-
ders and to change with age in a highly individualized process
and rate. They may be modified negatively or positively by many
factors such as activity types and frequency, medical conditions,
and nutritional factors. The alteration of posture, active and pas-
sive range of motion of the hip and knee joints, and gait during
physical activities are associated with age and gender as well.
51
An individuals weight and height directly influence the hip
and knee joint moments.
71
Height can influence limb size and
therefore lever arm. Daily physical activities such as walking and
Chapter 7b Reducing internal joint load: application of biomechanical concepts 277
stair climbing exert 3.5 BW on hip and knee forces. A change of
5 pounds of BW, for instance, may therefore result in 17.5 pounds
of excess force in the knee and hip. Additionally, an individuals
weight has been associated with the prevalence of joint pain
1
and
change in properties of tissue characteristics.
11
Aging is associated with a decrease in neuromuscular control
characterized by the decline of maximum muscle force produc-
tion, the velocity of contraction, and the dynamic stability.
33
Human muscle strength attains its peak between the ages of 20
and 30 years and declines gradually until the age of 60 and rigor-
ously thereafter.
31
During the single-leg support phase of walking
and stair climbing, while the body is moving forward, lower
extremity muscular strength is required to control and support it.
34
Often a lack of joint strength or an inability to develop torque
within the appropriate time may contribute to the risk of injury.
71
Stair descent by the elderly has previously been described as a
controlled fall due to the lack of ankle flexibility and strength as
well as the delay in developing torque rapidly.
72
It has been suggested that absolute task demands for perform-
ing activities of daily living are not significantly high; however,
older adults difficulty in performing these activities must take
into account their decrease in capacity.
23
Using inverse dynamics
analysis, Figure 7b.5 compares the knee joint moments of healthy
young and older adults during stair ascent and descent and when
rising from a chair compared with maximal isometric effort in supine
leg press. Although there is no significant difference between
absolute knee moments during physical activities, motor tasks
demand substantially greater effort relative to available maximum
capacity of elderly compared with young adults. As illustrated in
Figure 7b.5, relative effort was significantly higher for stair ascent,
54% for younger compared with 78% for older adults, stair descent
required 42% compared with 88% relative effort, and chair rising
required 42% compared with 80%. Compared with young adults,
the elderly walk at a significantly higher rate of oxygen uptake
(about 20% more) and physiologic relative effort, that is, the ratio of
the required oxygen uptake to the available maximal capacity.
5,23
Age has been hypothesized to cause a redistribution of joint
torques and power during gait. DeVita and Hortobagyi
15
reported
that during self-selected walking speed, elderly adults had 58%
greater angular impulse and 279% more work at the hip and 50%
less angular impulse and 29% less work at the knee compared
with young adults. Similarly, they reported 23% less angular
Figure 7b.5 Mean of body mass-normalized knee joint moments for healthy young adults of 22 years and old adults with a mean age of 74 years
during stair ascent (A), stair descent (B), and sit-to-stand (C). For stair ascent and descent, one cycle represents the initial foot contact (0) with
the stair to toe-off (100%). For rising from a chair, one cycle corresponds to lift-off (0) to fully erect position at the end of the rise (100%). The bar
graphs represent the group mean of the maximal isometric knee joint moments measured at specific knee joint positions in a leg press task. Solid
lines and filled columns indicate older adults, and dashed lines and open columns denote young adults. (From Hortobagyi T, Mizelle C, Beam S,
DeVita P: Old adults perform activities of daily living near their maximal capabilities. J Gerontol A Biol Sci Med Sci 58:M453-M460, 2003.)
impulse and 29% less work at the ankle for the elderly compared
with young adults. The elderly use less of the ankle plantar
flexors and knee extensors and more of the hip extensors.
15
Anatomic variation
In addition to variation in the size of muscle and bone, many
known anatomic variations directly influence the hip and knee
joint forces. For instance, the femoral neck has two angular rela-
tionships with the femoral shaft: the neck-to-shaft or inclination
angle and the torsion or anteversion angle. The inclination angle
of the femur is referred to the relation of the femur neck with the
shaft in the frontal plane. The inclination angle is about 140 to
150 degrees at birth and usually reduces to approximately
125 degrees, with a range of 90 to 135 degrees in adulthood. These
abnormal angles alter the alignment between the acetabulum
and femoral head and thereby alter the hip moments by chang-
ing the lever arm and the effect of upper body forces on the
joint. The inclination angle may have positive and negative bio-
mechanical effects.
49
The torsion angle of the femur is the rela-
tive rotation that exists between the neck and the shaft.
Normally, an infant is born with about 30 degrees of torsion
angle that usually decreases to 15 degrees by 6 years of age.
55,75
Excessive anteversion is often associated with a tendency toward
internal rotation of the leg during gait, change of contact area
between the femoral head and the acetabular,
50
and wear on the
articular cartilage.
The Q-angle is another reported anatomic variation. During
active knee extension and passive stretch, several structures guide
the patellar movement with respect to the tibiofemoral joint.
Although each structure alone may force medial or lateral
movement of the patella, the net result of these forces moves it
through the groove with minimal stress to the articular surfaces.
The degree that the quadriceps tends to pull the patella is known
as the Q-angle, which varies between the genders
24
and is not
bilaterally symmetric.
37,38
A Q-angle of greater than 15-20 degrees
is often thought to contribute to high articular stress and the
poor tracking of the patella, thereby leading to arthritis, chondro-
malacia, recurrent patellar dislocation, or patellofemoral joint
pain syndrome. Although in apparently normal anatomic struc-
ture the Q-angle and femoral neck angle of inclination and tor-
sion is not necessarily consistent with the appropriate knee and
hip joint loading during physical activities, the abnormal range
of these angles is usually an indication of abnormal joint loading
and pain.
Medical history and disease stage
Medical history such as osteoarthritis
45
and ligament deficiency
35,67
may alter the kinematics and kinetics of the hip and knee joints
directly or indirectly. Hip and knee osteoarthritis results from
degenerative changes in cartilage that to some extent result from
arbitrary increases in joint loading.
19
For instance, patients with
advanced knee osteoarthritis walk with lower ground reaction
forces and reduced sagittal plane range of motion,
45,66
increased
knee adduction moment,
6
decreased stride length,
3
and increased
angling out of the toes.
73
Although self-selected walking speed
has been reported to explain only 8.9% of the variation in the
maximum knee adduction moment, a patients walking style is
associated with the severity of knee osteoarthritis.
45
One study
has shown that knees with more severe osteoarthritis have greater
adduction moments and more varus alignment than those in
which osteoarthritis is less severe.
45
Figure 7b.6 demonstrates the magnitude and slope of the the-
oretical relationship between the maximum knee adduction
moments and the walking speeds for two groups of patients with
different degrees of knee osteoarthritis severity compared with
asymptomatic control subjects matched for age and sex. The vari-
ation of the slopes in Figure 7b.6 indicates that adopting differ-
ent walking speeds may not equally benefit osteoarthritis patients.
Patients with less severe knee osteoarthritis walk with unique gait
mechanics that are different from those of the control group and
those of patients whose knee osteoarthritis is more severe.
45
Similarly, other studies have demonstrated the effects of hip
osteoarthritis and pain on the hip forces and gait.
25
In summary, the kinematics and kinetics of the knee and hip
joints are directly or indirectly influenced by individual factors.
A brief discussion of some of these factors mainly serves as an
example of how they may influence hip and knee joint forces.
Although these individual factors cannot be controlled or mod-
ified, understanding their relationship with their influencing
mechanism helps to explain the individuals tolerance, ability to
perform physical tasks, neuromuscular adaptation, and variation
in the magnitudes of joint forces. Whereas most reported studies
in this section discuss and compare healthy individuals with
certain groups such as the elderly or individuals with severe
osteoarthritis, who may not represent the working population,
the information can still demonstrate the process and direction of
biomechanical change.
4.0
3.0
2.0
1.0
1.0 1.5 0.5
Walking speed (m/s)
M
a
x
i
m
u
m

k
n
e
e

a
d
d
u
c
t
i
o
n

m
o
m
e
n
t
(
%

b
o
d
y

w
e
i
g
h
t

h
e
i
g
h
t
)
More severe
knee OA
Asymptomatic
Less severe
knee OA
Figure 7b.6 Relationship between maximum knee adduction moment
and self-selected walking speed for three groups of subjects: patients
with knee osteoarthritis (OA) of lesser and greater severity and matched
control subjects. (From Mundermann A, Dyrby CO, Hurwitz DE, Sharma L,
Andriacchi TP: Potential strategies to reduce medial compartment
loading in patients with knee osteoarthritis of varying severity: reduced
walking speed. Arthritis Rheum 50:1172-1178, 2004.)
Reduction of joint forces and moments
Many physical activities such as walking, running, and stair
climbing involve coordinated cyclic movements of several joints.
Often, the comprehensive kinetic and kinematics analysis of
single joints such as the hip or knee requires understanding their
function in relation to other joints and their crossing muscles.
The internal joint forces during dynamic physical activities are
produced by BW, externally carried loads, and internal soft tissue
forces such as muscles. A practical method of reducing joint force
is to reduce the lever arm and impact of external forces. Several
biomechanical and physiologic factors underlie the mechanism
to reduce joint loads during physical activities and thereby risk
of injury.
Reducing the lever arm
The primary function of the hip joint is to support the weight of
the head, arm, and trunk both in static erect posture and in
dynamic activities such as walking, running, and stair climbing.
The most effective means of reducing the joint forces during
daily activities is to find a practical method of reducing the mag-
nitude of either these forces or the lever arm. The hip and knee
joint forces need to be understood largely in the context of
action of the upper BW on the lower extremity. For example, the
magnitude of the torques on the hip joint during upright stand-
ing is equal to the weight of the upper body (W), which is equal
to two thirds of BW
50
times the distance of this force from the
hip joint axis. As shown in Figure 7b.7A, during a single-legged
stance, assuming the lever arm is 4 inches,
52
for a 180-pound
individual, the gravitational force at the hip is as follows:
Hip joint moment = (upper BW + lower leg weight) lever arm
Assuming the weight of lower leg is one sixth of BW, the acting
moment is as follows:
= (2/3 BW + 1/6 BW) lever arm
= 5/6 BW 4 = 150 4 = 600 lbs/in
Often individuals with painful hip or abductor weakness may
lean their upper bodies over the painful hip to reduce the pain
or may display a Trendelenburg (abductor lurch) gait pattern.
59
When the pelvis rotates and the trunk is laterally flexed toward
the stance limb, the moment arm may reduce substantially with
respect to the neutral trunk. If the lever arm decreases from 4 to
2 inches (Fig. 7b.7B), the hip joint moment proportionally
reduces to half.
In a series of three experiments, Neumann
48
compared the
electromyography activity of the hip abductor muscles in sub-
jects with hip prostheses adopting different methods of walking
while using canes and carrying external loads. Twenty-four
subjects with unilateral hip prostheses carried loads weighing
5%, 10%, or 15% BW and held by either their contralateral or
ipsilateral arms relative to their prosthetic hips. As shown in
Figure 7b.8, it was assumed that during the midstance phase of
walking, the hip abductor muscle generated a very large force
proportional to the BW and varied with a relatively small
moment arm. Neumann found that the use of a cane on the con-
tralateral side and the ipsilateral load condition could reduce the
muscle activities by 40% of baseline as compared with walking
without a load or a cane.
Synergic movement and muscular coactivation
The force produced by a given muscle with specific size and
structure depends on the activation level, length, and speed of
contraction. The interaction of these parameters and their influ-
ence on muscle force production has been discussed in most
basic textbooks of skeletal muscle biomechanics and physiology.
Generally, it is known that tension generated in a skeletal muscle
is a function of its length and the magnitude of overlap between
the actin and myosin filaments. As the load increases, the velocity
at which a muscle shortens while undergoing maximal stimulation
decreases. During physical activities involving the lower extremity,
muscle length changes due to the synergy among the monoartic-
ular and biarticular muscles of the hip and knee joints.
During functional activities, often the biarticular muscles have
antagonistic activities at one joint and agonistic activities at
another.
4
During stair climbing, for example, the rectus femoris
acts as the knee agonist muscle by providing the knee extension
moment and as the hip antagonist muscle by providing the hip
flexion moment.
4
At times a muscle is even antagonist in one
plane and agonist in another. Except for the short head of the
Figure 7b.7 Normal pelvis and hip orientation during upright standing (A) and pelvis position during abductor lurch and Trendelenburg (B).
(From Robertson DD, Britton CA, Latona CR, Armfield DR, Walker PS, Maloney WJ: Hip biomechanics: importance to functional imaging. Semin
Musculoskelet Radiol 7:28-41, 2003.)
Weight
Moment Arm
Weight
Moment Arm
A B
biceps femoris and the popliteus, all knee flexors are biarticular
muscles, and their ability to produce force is influenced by the rel-
ative position of the two joints over which they cross. And except
for the gastrocnemius, all muscles that cross posterior to the knee
have the ability to flex and internally or externally rotate it.
As a joint angle varies during physical activity, changes in the
muscle length and in its effective moment arm at the joint result
in torque variation.
42
For the biarticular muscle of the hip and
knee, it has been shown that change of angle at one joint and
elongation of the muscle have been accompanied in most cases
by greater torque production, an example being the effect of the
hip angle on the knee extensor or flexor torque.
Mohamed et al
42
investigated the influence of length change
on the electromyographic activity of six knee flexor muscles. As
shown in Figure 7b.9A, regardless of the knee position, extended
hip position was associated with significantly less torque than
that of the other two flexed hip positions. Similarly, 90-degree
knee flexion influenced the flexor muscle torque independent of
the hip angle. Because the hamstring muscle length was short-
ened at both joints, the extended hip position and the 90-degree
knee flexion resulted in the least torque production.
The highest knee flexion torque was 90 degrees at the hip
position and 45 degrees of knee flexion rather than extension.
Similar results have been reported by other investigators that the
peak torque occurred during the 45-degree knee flexion, where
the flexor muscles were not fully stretched. In addition to the
knee flexion torque, Smidt
64
measured the lever arms of the knee
flexors in a series of radiographs. He found that the hamstring
moment arm is about 2.50 cm in 5- and 90-degree knee flexion,
but it increases to 4.08 cm as the knee reaches 45 degrees. These
findings suggest that besides the length-tension relationship, the
hamstring lever arm compensates for the decrease of muscle
length that occurs during knee flexion (Fig. 7b.9B).
42
Two-joint muscles provide several advantages in the control
of the musculoskeletal system during physical performance.
First, biarticular muscles couple the motion of the two joints in
that they cross and redistribute muscle torque, joint power, and
mechanical energy throughout a limb. Second, the shortening
velocity of biarticular muscles is less than that of monoarticular
muscles. Therefore, a comprehensive biomechanical analysis of a
physical task should include a careful analysis of co-contraction
biarticular muscles and synergic activities among all joints in bal-
ancing internal and external forces.
Joint forces during daily living activities
The muscular demand and internal forces on the joint and soft
tissues during daily physical activities may provide valuable
information about how they interact. Understanding the factors
that may modulate the demand of these activities on the inter-
nal forces can be extremely valuable for assessing the effects of
tasks that occur routinely at home and at work.
Squatting
Dynamic squatting is an integral part of occupational
27-29,68
and
daily living activities, especially in non-Western cultures,
22,44
and
is the essential part of the strength and conditioning programs for
rehabilitation and many sports that require high levels of strength
and power.
18
Half squatting, in which the posterior thighs are
parallel to the ground with approximately 0-100 degrees of knee
flexion, is more commonly discussed and recommended in the
literature rather than deep squatting, in which the posterior
thighs and legs make contact. Dynamic squatting is generally
discussed in the context of the tibiofemoral and patellofemoral
forces, the knee muscle activities, and the joint stability.
Escamilla
18
reviewed selected studies that have quantified the
knee force during dynamic squatting. The posterior cruciate lig-
ament restrains low to moderate posterior forces for all of the
knee flexion angles throughout squatting. The anterior cruciate
ligament restrains low forces from 0 to 60 degrees of knee flex-
ion. During dynamic squatting, peak posterior cruciate ligament
forces are estimated to range from 295 to 2704 N, peak anterior
cruciate ligament forces from 28 to 500 N for 0 to 60 degrees of
knee flexion, and peak compression from 550 to 7928 N.
Because the ultimate failure load is reported to be 4000 N
54
for
the posterior cruciate ligament and from 1725 to 2160 N for the
anterior cruciate ligament,
53,74
dynamic squatting should not
injure healthy joints.
18
Although squatting and kneeling are common activities among
many populations,
22,27-29,44
only a limited number of studies have
investigated the biomechanical consequences during such deep
flexion activities.
22
Hefzy et al
22
used biplanar radiographs to eval-
uate knee kinematics in deep flexion and showed that the motion
of the femur did not reveal rollback on the tibia beyond 135
degrees of flexion. Another kinematic study by Dyrby et al
17
Figure 7b.8 The mean of normalized electromyography produced by
the hip abductor muscles during three walking conditions: walking with
contralateral (CL) cane and ipsilateral (IL) load, with contralateral cane,
and with ipsilateral load. Loads are 5%, 10%, and 15% BW. The hip
abductor electromyogram is normalized to normal control walking
conditions. (From Neumann DA: An electromyographic study of the hip
abductor muscles as subjects with a hip prosthesis walked with
different methods of using a cane and carrying a load. Phys Ther
79:1163-1173, 1999.)
showed the relationship between deep knee flexion and
internal/external rotation during deep squatting. Dahlkvist et al
14
calculated joint and muscle forces from data collected from six
subjects performing squatting and rising from a deep squat.
Compared with the forces during normal walking,
41,43
they esti-
mated the tibiofemoral joint forces to vary from 4.7 to 5.6 times
the BW vertically and 2.9 to 3.5 times the BW horizontally. Other
investigators studied different styles of sitting and standing that
require deep knee flexion. As shown in Figure 7b.10, deep flexion
activities generate large quadriceps moments and net posterior
forces depending on the style of ascension. The net moments
and posterior forces increase along with the flexion angle.
As Figure 7b.10 shows, net quadriceps muscle activity during
double leg descending is about twice the single leg descending.
Fry et al
20
studied knee joints under external load, the barbell
squat technique, the restricted forward displacement of the knees
past the toes versus non-restricted movement, and the knee posi-
tion on the hip and knee torques. Seven weight-trained men were
videotaped while performing parallel barbell squats with loads
equal to their BWs. The study showed significant (p < 0.05) dif-
ferences between the static knee and the hip torques, and the
restricted squat produced more anterior lean of the trunk and
shank and greater angles at the knees and ankles. The restricted
squat produced knee torque of 117.3 (34.2) Nm and hip torque
of 302 (71) Nm, whereas the unrestricted squat produced knee
torque of 150 (50) Nm and hip torque of 28 (65.0) Nm.
The squat technique and stabilization mechanism to balance
the whole body can affect the large net quadriceps moments and
Figure 7b.9 (A) The maximum isometric knee torque and electromyographic data collected during a series of nine combinations of the knee and
hip position for 19 healthy subjects. (B) The maximum isometric knee flexion torque for three positions of the knee and two hip angles. (From
Mohamed O, Perry J, Hislop H: Relationship between wire EMG activity, muscle length, and torque of the hamstrings. Clin Biomech 17:569-579, 2002.)
800
700
600
500
400
300
200
100
0
0 degree
45 degree
Knee position
90 degree
T
o
r
q
u
e

(
k
g
c
m
)
90 degree
0 degree
H
i
p

p
o
s
i
t
i
o
n
B
A
Hip at 0 Knee at 0(00-00) Hip at 0 Knee at 45(00-45) Hip at 0 Knee at 90(00-90)
Hip at SLR Knee at 0(SLR-00) Hip at SLR Knee at 45(SLR-45) Hip at SLR Knee at 90(SLR-90)
Hip at 90 Knee at 0(90-00) Hip at 90 Knee at 45(90-45) Hip at 90 Knee at 90(90-90)
The nine test positions.
net internal forces of the knee and hip joints. The loads on the
knee during deep flexion are important for both knee pathogene-
ses and rehabilitation programs for patients with total knee
arthroplasty. Although some squatting techniques such as
restricting forward movement of the knees may minimize their
stress, it is likely that such techniques may inappropriately trans-
fer mechanical stress to the hips and low back.
Stair climbing and walking
Like walking, stair climbing is a common daily activity that has
been associated with a large number of cyclic joint loadings. If
these activities are accompanied by pain and instability, they
increase the perception of disability.
13
Although stair climbing
and walking are performed easily by healthy persons, they are
quite demanding when joints or motor functions have been
altered by disease or injury. Especially during their single support
phase, adequate joint strength and control are critical to support
the entire body mass and move the body forward.
Despite the similarity between these two physical activities,
adequate muscle strength and joint range of motion for level
walking does not ensure the individuals ability for stair climbing.
The differences between these modes of locomotion might be
significant for individuals with physical impairments. Compared
with level walking, stair climbing requires 15 to 20 degrees more
knee and hip flexion.
46
Bergmann et al
8
reported the peak hip
contact forces and torsional moments measured by instrumented
implants during different common physical activities. The average
hip joint load was 238% BW while walking 4 km/h, 251% BW
while ascending stairs, and 260% BW while descending stairs.
The most critical aspect of stair climbing is the inward torsion,
which is 23% larger during ascent than walking.
The number of parameters studied during stair climbing has
been limited, in particular in the frontal plane. Nadeau et al
46
studied and compared stair climbing and level walking during a
preferred speed in healthy adults over 40 years old. The net
moments and powers were estimated with an inverse dynamic
approach. The researchers reported a significantly shorter stance
time and longer mean cycle duration for stair climbing than for
level walking. In comparison with level walking, greater flexion
of the lower limb was observed at the beginning of the stair
climbing cycle (foot strike) and less extension at the hip was
observed at toe-off with concentric action of the abductor mus-
cles that raise the pelvis on the contralateral side. Although the
same muscle groups are used in stair climbing and walking,
major differences were observed in the patterns of the knee flex-
ors and extensors and the hip abductors and in the magnitude of
the knee dorsiflexion during the swing phase. The moments and
powers indicated a different action of the hip abductors across
Figure 7b.10 The mean and standard deviation of the net flexion moment (), net posterior force (), and net inferior force () during single-leg
(A) and double-leg (B) descent for 9 women and 10 men with a mean age of 29 years (range, 21-37). Stick figures indicate the sagittal image of
the limb during each motion. Net moments are normalized to the percent of body weight times the height (%BW Ht), and net force is normalized
to the percent of body weight (%BW). (From Nagura T, Dyrby CO, Alexander EJ, Andriacchi TP: Mechanical loads at the knee joint during deep flexion.
J Orthop Res 20:881-886, 2002.)
16
14
12
10
8
6
4
2
0
100
80
60
40
20
0
20
40
60
80
100
0 40 80 120 160 20 60 100 140
Double leg descending
Inferior force
Posterior force
Flexion moment
N = 19
N
e
t

f
o
r
c
e

(
%
B
W
)
N
e
t

m
o
m
e
n
t

(
%
B
W
*
H
t
)
B
16
14
12
10
8
6
4
2
0
100
80
60
40
20
0
20
40
60
80
100
0 40 80 120 20 60 100
Single leg descending
Inferior force
Posterior force
Flexion moment
N = 19
N
e
t

f
o
r
c
e

(
%
B
W
)
N
e
t

m
o
m
e
n
t

(
%
B
W
*
H
t
)
A
tasks to control the pelvis in the front plane of the stance phase
and the knee extensors in the sagittal plane.
Costigan et al
13
examined hip and knee joint kinetics during
stair climbing in 35 young healthy subjects using a subject-
specific knee model to estimate the bone-on-bone tibiofemoral
and patellofemoral joint contact forces. Net knee forces were
below one BW, whereas peak posterior-anterior contact forces
were close to one BW. The peak distal-proximal contact force
was on average three times BW and could be as high as six times
BW. These contact forces occurred at a high degree of knee flex-
ion, where there is a smaller joint contact area resulting in high
stresses. The peak knee adduction moment was 0.42 (0.15) Nm/kg,
whereas the flexion moment was 1.16 (0.24) Nm/kg. Similar peak
moment values, but different curve profiles, were found for the
hip. The hip and knee posterior-anterior shear forces and the knee
flexion moment were higher during stair climbing than during
level walking. The most striking difference between level walking
and stair ascent was that the peak patellofemoral contact force
was eight times higher during the latter.
The patterns for normal stair gait show the dominant role of the
knee during weight acceptance and pull-up, with the supporting
roles played by the hip and ankle.
40
The ankle has the major role
during forward continuance, with relatively little contribution
from the knee and hip. If the ankle is restricted, the higher forces
are therefore transferred to the hip and knee.
Task variables
In addition to the lever arm and magnitude of the external forces,
various task variables are known to influence gait or movement
pattern and thereby change the forces of the muscles and internal
joints. Task variables can be classified into two categories. The
first is those that are defined by the environment and cannot be
individually controlled, such as stair height and angle of inclina-
tion and chair height, armrest,
26,60
and surface condition.
63
For example, Riener et al
57
studied the influence of stair
climbing with three inclination angles of 24, 30, and 42 degrees
on the hip and knee joint biomechanics and motor coordination
(Figure 7b.11). The joint angles and moments showed relatively
small differences but depended significantly on the three inclina-
tion angles. The temporal gait cycle parameters and ground
1.4
1.2
1
0.8
0.6
0.4
0.2
0
0.2
0.4
0.6
0 40 20 60 80 100 30 10 50 70 90
Cycle time (%)
HIP POWER
N
o
r
m
a
l
i
z
e
d

j
o
i
n
t

p
o
w
e
r

(
W
/
k
g
)
Ascent
Level
walking
Descent
Max Norm
Min
Max
Norm
Min
3
2
1
0
1
2
3
4
5
0 40 20 60 80 100 30 10 50 70 90
Cycle time (%)
KNEE POWER
Ascent
Level
walking
Descent
Max
Norm
Min
Max
Norm
Min
2
1
0
1
2
3
0 40 20 60 80 100 30 10 50 70 90
Cycle time (%)
ANKLE POWER
Ascent Level
walking
Descent
Max
Norm
Min
Max
Norm
Min
A
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
0.2
0.4
50 10 30 10 30 50 20 40 0 20 40
Inclination (deg)
MAXIMUM JOINT MOMENTS
N
o
r
m
a
l
i
z
e
d

j
o
i
n
t

m
o
m
e
n
t

(
N
m
/
k
g
)
Hip
Knee
Ankle
4
3.5
3
2.5
2
1.5
1
0.5
0
0.5
1
50 10 30 10 30 50 20 40 0 20 40
Inclination (deg)
MAXIMUM JOINT POWERS
N
o
r
m
a
l
i
z
e
d

j
o
i
n
t

p
o
w
e
r

(
W
/
k
g
)
Hip
Knee
Ankle
B
Figure 7b.11 (A) Joint moments during level walking and stair ascent and descent at minimum (24 degrees), normal (30 degrees), and
maximum (42 degrees) inclinations, averaged for 10 healthy subjects. Joint moments are normalized by body weight. The cycle starts with foot
contact. The vertical bar indicates the toe-off, which divides the entire cycle into stance and swing phase. (B) Group mean and standard deviation
for joint powers and joint moments for hip (), knee (), and ankle () during level walking (0-degree inclination), three-stair descent (at angles
of 42, 30, and 24 degrees), and three-stair ascent (at angles of 24, 30, and 42 degrees). The solid lines show linear regressions.
(From Riener R, Rabuffetti M, Frigo C: Stair ascent and descent at different inclinations. Gait Posture 15:32-44, 2002.)
reactions were not significantly affected, but joint powers were
significantly influenced by stair inclination. The maximum joint
powers in the hip and ankle change up to 67% with the inclina-
tion and can be attributed to the amount of potential energy
produced during ascent or absorbed during descent by the
muscles. The kinematics and kinetics of staircase walking differ
considerably from those of level walking.
A review of the literature indicated that a chair seats height,
the use of armrests, and foot position have major influences on
the sit-to-stand ability and the kinematics and kinetics of the
lower extremity joints. Using a higher chair seat results in signif-
icantly lower moments at the knee (up to 60%) and hip (up to
50%) joints, whereas lowering the seat height makes sit-to-stand
movement more demanding or even occasionally impossible.
26
Reducing the seat height can alter the bodys stabilizing strategy
and biomechanical profile, such as the increase in its center of
mass travel distance and momentum needed to initiate the move-
ment and the range of motion of the ankle, trunk, and knee.
26
Conversely, maximum knee flexion moments were found to be
highly dependent on chair height and nearly doubled from the
lowest to the highest position from 6 BW at 115% of knee height
to 3 BW at 65% of knee height.
60
As shown in Figure 7b.12,
moreover, a more posterior foot position allows both a lower
maximum mean extension moment, 32.7 Nm at posterior versus
148.8 Nm at anterior, and a shorter movement time.
32
Additionally, the use of the armrests reduces the moments needed
at the knee and by 50% those needed at the hip. A chair with
adequate height, sufficient space underneath, and armrests
should therefore be recommended for patients with prosthetic
devices,
60
as well as for individuals with painful joints and low
hip and knee strength.
The second category of task variables consists of those that
individuals may be able to control such as shoes, speed of move-
ment, and style of movement gait. Peak force is sensitive to walk-
ing speed.
69
Bergmann et al
8
studied the influence of footwear
and walking or running style. One subject with an instrumented
hip implant wore different sports shoes, normal leather shoes,
hiking boots, and clogs and walked barefoot with soft normal
and hard heel strikes. The loads were the lowest while walking
and jogging without shoes. The torsional loads rose up to 50%
with shoes, whereas the hip bending moment at the implant
slightly changed. The investigators concluded that soft heel
strikes with smooth gait patterns are the only means to reduce
joint loading. Soft heels, soles, or insoles did not offer advan-
tages, and no relationship was found among different types of
shoes. Shoes with very hard soles, however, increased the joint
load and were clearly disadvantageous.
CONCLUSION
Physical activities of daily living such as walking, running, and stair
climbing involve cyclic activities coordinated among several joints.
Kinetic and kinematic analyses of the hip and knee therefore
Chapter 7b Conclusion 285
Figure 7b.12 The pathways of the center of gravity (COG) in a sagittal plane during two methods of foot placement in the initial stage of standing
up from a chair (height, 40 cm). In the first method, with anterior foot placement, the COG moves forward and then up with the knee joint
extension. In the second method, with posterior foot placement, the COG moves up from the early stage after lift-off with the hip joint and trunk
extension. The initial position of the COG is defined as 0. The positive values correspond to forward and up. T1 indicates the beginning and T3 the
end of the movement, whereas T2 indicates the beginning of different joint extensions. (From Kawagoe S, Tajima N, Chosa E: Biomechanical
analysis of effects of foot placement with varying chair height on the motion of standing up. J Orthop Sci 5:124-133, 2000.)
require an understanding of joint activities in relation to the
whole body in the context of external loads and adapted posture.
Kinematic and kinetic analyses of the hip and knee joints
enhance our understanding of factors influencing external and
internal forces and injury risks. Additionally, biomechanical con-
cepts and simple biomechanical models provide reasonable esti-
mates of factors differing among individuals, physical activities
being undertaken, and task variables. A careful analysis of these
factors provides a practical method of reducing musculoskeletal
loads by altering external loads or modifying techniques for exe-
cuting physical daily activities, thereby reducing risk of injury.
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Clinical Evaluation
of the Hip and Knee
Craig J. Della Valle, Benjamin Crane, and Gunnar B. J. Andersson
A careful clinical evaluation of the hip and knee is important
to determine the presence of disease or injury for the purpose
of establishing the nature of a complaint. Only by means of an
accurate diagnosis is it possible to determine an appropriate
treatment. Given the importance of a thorough history and phys-
ical examination, textbooks are available that deal with this topic
in great detail. It is beyond the scope of this chapter to provide
a complete description of all the tests that are available to evalu-
ate the hip and knee. Rather our goal is to provide the clinician
with the basic skills needed to diagnose accurately and begin
treatment appropriate for occupationally related complaints.
Although advances in diagnostic imaging continue to improve
our ability to identify anatomic abnormalities, these often do not
correlate with clinical signs and symptoms. For this reason, indis-
criminate ordering of advanced imaging studies is discouraged,
particularly in patients with occupationally related complaints.
In cases for which they are deemed necessary, plain radiographs
can point the physician to a correct diagnosis of most com-
plaints when these tests are combined with a thorough history
and physical examination.
HISTORY
Obtaining a medical history from a patient with an occupation-
ally related complaint is somewhat different from doing so with
a more general complaint: Occupational factors may provide
additional information useful to obtain a correct diagnosis,
and any relationship between the complaint and the patients
vocation can have important legal, medical, and rehabilitative
implications. The history should be structured, and the use of a
checklist or standardized form is useful to ensure that all critical
portions are carefully obtained and documented. An example of
a structured history is shown in Table 7c.1.
The history should begin by identifying the chief complaint
and injury mechanism. All events should be carefully documented
in chronological order. Although patients with hip pathology
typically report pain in the groin, pain in the area of the greater
trochanter or buttock is not uncommon. A history of difficulty
in donning shoes suggests loss of hip range of motion and arthritis.
In patients complaining of knee pain, it is important to docu-
ment where the pain is located (anterior, posterior, medial, or
lateral) and whether it is associated with swelling, sensations of
instability (suggestive of a ligamentous injury), or mechanical
symptoms such as locking or clicking that may point to a
meniscal pathology or a loose body. Associated symptoms such as
numbness and tingling (characteristic of lumbar radiculopathy)
that suggest alternative sites for pathology are also important to
note. It is especially important to determine whether there are
activities that exacerbate or improve the patients symptomatology
to ascertain return to work status.
Although past treatment of a particular problem is generally
a crucial criterion for determining further treatment, in an occu-
pational injury the complaint is typically referable to a triggering
event (accident). It is important, however, to determine whether
the present complaint is referable to a joint that has been
symptomatic or injured in the past, because this may be a criti-
cal point in ascertaining whether the event in question caused
an initial injury or aggravated a preexisting condition. Specific
questions regarding childhood problems are particularly important
in patients with complaints of hip and groin pain because devel-
opmental problems can become symptomatic later in life. Past
medical history is important to ensure an appropriate evaluation
(in a person with a history of malignancy, for example, metastatic
disease can be considered among the potential diagnoses). The
patients social history, including information about recreational
habits, smoking, alcohol intake, and family life, are all important
pieces of a thorough evaluation and paint a fuller picture of the
person being examined.
Hip
The physical examination of a patient with a complaint of hip
pain begins with an observation of the gait pattern. The patient
needs to be sufficiently undressed so that movements of the hip
and knee can be observed appropriately. The two most common
C HA P T E R
7c
Table 7c.1 Example of structured history
History of present illness
What is the chief complaint (e.g., left knee pain)?
When did the symptoms begin?
How did they start? Was an accident or specific activity involved?
What do you believe caused the symptoms? Why?
Where exactly is the pain located (i.e., anterior knee, back of knee, inside
of knee)?
How would you describe your pain (i.e., throbbing, sharp, dull, tightness)?
Are there activities that make your pain worse?
What activities make your pain better?
Do you have any associated symptoms such as stiffness, swelling,
or weakness?
What previous treatment have you had related to this complaint?
Have radiographs or other tests been performed?
Previous history of injury or problems with the affected joint
Past medical history
Occupational history
Social history
Review of systems
gait patterns observed are an antalgic gait and a Trendelenburg
or gluteus medius gait.
An antalgic gait pattern results from the patients attempt
to decrease weight bearing on the painful hip by decreasing
the amount of time spent in stance phase on the affected side
and thus the resulting pain. A Trendelenburg gait results from
weakness of the hip abductor muscles (the luteus medius and
minimus). In its normal state, the abductor musculature holds
the pelvis level during the swing phase of gait; when the abduc-
tors are weakened, the pelvis drops on the side contralateral
to the affected hip. The patient compensates by shifting the
trunk in the opposite direction to maintain the center of gravity
closer to the stance leg.
The Trendelenburg test involves asking the patient to stand
on one leg and then observing movements of the trunk and
pelvis (Fig 7c.1). Normally, when the patient stands on the right
leg, the gluteus medius on that side contracts to keep the pelvis
level. If the muscle is weak or paralyzed, the pelvis on the con-
tralateral sidethe left side, for exampledrops and the patient
compensates by listing the trunk to the right. The test is typically
recorded as positive (abnormal) or negative. It is positive most
commonly in arthritic conditions, but patients with neurologic
disease or with palsy of the superior gluteal nerve have similar,
if not more dramatic, findings.
With the patient still standing, the skin overlying the hip is
inspected for abrasions, discoloration or ecchymosis, swelling,
atrophy, or other deformity. The presence or absence of pelvic
obliquity is determined next by identifying the anterior superior
iliac spines, the iliac crest, and the greater trochanter; these struc-
tures should be symmetrically level bilaterally, and if not, pelvic
obliquity is present.
The patient is then placed supine on an examination table for
a determination of leg lengths. A general assessment involves
examining the relative positions of the soles of the feet and the
medial malleoli. Keep in mind, however, that this measurement
will not differentiate between a true leg length discrepancy and
an apparent discrepancy that can be caused by pelvic obliquity
or more commonly a hip flexion contracture. Actual leg length
can be measured with a tape measure as the distance between the
anterior superior iliac spine and the medial malleolus bilaterally
(Fig. 7c.2). Apparent leg length discrepancy is measured from the
umbilicus to the medial malleolus.
The hip is next palpated to determine areas of tenderness.
The greater trochanter can be tender after a fall on the affected
side, but tenderness is more commonly associated with a
trochanteric bursitis or insertional tendonitis. The femoral triangle
anteriorly, the sciatic notch posteriorly, and the individual mus-
cles around the hip should be palpated also to determine areas
of maximal tenderness; these may represent a contusion or strain
injury secondary to acute trauma or tendonitis or bursitis from
less acute processes.
The patient is then asked to straight leg raise or to lift the leg
off the examination table with the knee extended. An inability to
do so may indicate a femoral neck fracture, particularly in the
setting of acute trauma, and thus plain radiographs should be
obtained before proceeding further with the examination. The leg
can also be passively elevated with the knee extended, and if shoot-
ing pain is experienced down the leg past the knee, particularly
down the contralateral leg, a lumbar source of pain should be
sought (see Chapter 4c). Range of motion is then measured with
the patient supine. A complete examination includes measure-
ment of flexion, extension, internal rotation, external rotation,
abduction, and adduction. To identify a hip flexion contracture,
the Thomas test is performed: The contralateral hip is maximally
flexed to eliminate the lumbar lordosis, and then residual flex-
ion, if any, is measured (Fig. 7c.3). Normal range of hip flexion
is 120 to 135 degrees (Fig. 7c.4). Internal and external rotation of
the hip are measured next with the patient still supine and the knee
flexed 90 degrees; normal ranges for internal rotation are 30 to
45 degrees and for external rotation, 45 to 60 degrees (Fig. 7c.5).
Chapter 7c Clinical evaluation of the hip and knee 290
Figure 7c.1 Trendelenburg test. The unaffected hip drops when
standing on the affected leg.
Intraarticular conditions of the hip cause pain with rotatory
movements, and a loss of internal rotation in particular is an
early indicator of hip disease. Abduction and adduction
are measured next while keeping one hand on the patients pelvis
during testing to ensure that pelvic motion is not confused for
true hip range of motion (Fig. 7c.6). Normal ranges for hip
abduction are 45 to 50 degrees and for hip adduction, 20 to
30 degrees. Hip extension is measured next and is most com-
monly performed with the patient prone; a normal range is 20 to
30 degrees (Fig. 7c.7).
Muscular strength can be assessed next and should include
direct testing of the hip flexors (iliopsoas and rectus femoris
muscles), the hip extensors (gluteus maximus muscles), and the
hip abductors and adductors. Hip flexion is tested most easily
with the patient seated and asked to flex the hip against manual
resistance; pain during this maneuver may indicate iliopsoas
tendonitis. Hip extensor strength is most easily tested with the
patient prone. Although the hip abductors have already been
tested indirectly by gait observation and with the Trendelenburg
test, with the patient in the lateral decubitus position, direct
muscle strength testing can be performed. Pain with resisted
Figure 7c.3 The Thomas test is used to detect flexion contractures
of the hip and to evaluate the range of hip flexion.
Figure 7c.4 Hip flexion is normally 120 to 135 degrees.
35
0
45
Figure 7c.5 Rotation tested in the flexed position is normally 30 to
45 degrees internal and 45 to 60 degrees external.
Figure 7c.2 Leg length should be measured from the anterior
superior iliac spine to the medial malleolus.
hip abduction may be further evidence of a trochanteric bursitis.
Hip adduction is tested most easily with the patient supine and
asked to adduct the hip actively from an abducted position.
Although not directly related to the hip, a brief neurologic
examination of the lower extremities is imperative to ensure that
lumbar radiculopathy is not present; this should include a test of
deep tendon reflexes and a motor and gross sensory examination.
Knee
The physical examination of the knee follows closely the form
seen for that of the hip. As previously discussed, the patient
must be sufficiently undressed to view the lower extremity in its
entirety. Gait is typically examined first. Although an antalgic
gait (decreased stance phase on the affected side to decrease pain)
is most common, the presence of a Trendelenburg gait (indica-
tive of hip pathology) is critical to identify because patients
with hip pathology can present with pain that is primarily
referred to the knee. While the patient is still standing, examine
the overall alignment of the extremity (Fig. 7c.8). Normally, the
lower extremity is in slight (4-6 degrees) valgus alignment with
larger amounts of varus or valgus typically associated with longer
term pathology, such as arthritic conditions. Although unusual,
muscular wasting should be sought, typically in association
with neurologic pathology or disuse. Subtle muscular atrophy
indicative of more chronic pathology can be ascertained with a
tape measure placed around the thigh at symmetric points on
the affected and unaffected limbs (e.g., at a specific distance as
30
0
Figure 7c.7 Hip extension is normally 20 to 30 degrees.
Normal Valgus Varus
Figure 7c.8 Varus/valgus deformity of the knee.
A B
Figure 7c.6 (A) Abduction and (B) adduction. Abduction is normally 45 to 50 degrees, and adduction is normally 20 to 30 degrees.
measured from the medial joint line). Long-standing subjective
complaints of knee pain without substantial (more than 5 mm)
side-to-side difference in girth should be viewed skeptically by
the examiner.
In the setting of an acute accident, the skin is carefully
inspected for abrasions, ecchymosis, or swelling. The patient can
then be placed supine and the knee examined for an effusion or
generalized knee swelling (Fig. 7c.9). In the setting of an acute
injury, a very large effusion may indicate an intraarticular frac-
ture, a ligamentous disruption, or an acute meniscal tear. With
a more long-standing history of knee pain, an effusion can sug-
gest arthritis or a meniscal tear. More localized areas of swelling
can occur anteriorly (directly over the patella), indicating a
prepatellar bursitis that can be associated with long periods of
kneeling. Some patients (particularly males) may have an area
of apparent swelling anterior to the tibial tubercle, just distal to
the insertion of the patellar tendon. When palpated, this area
is hard and represents bony overgrowth secondary to Osgood-
Schlatter disease, a self-limited process that is rarely problematic
other than for a cosmetic protuberance in the area. A localized
area of swelling in the posterior aspect of the knee suggests
a Bakers cyst. Typically not the result of a primary process,
a Bakers cyst is secondary to arthritis or a meniscal tear,
which induces an effusion that expands in the direction of least
resistance.
Because many of the important anatomic structures about
the knee are subcutaneous, careful palpation can often identify
the site of pathology. Tenderness directly over the patella can
indicate either a contusion or a fracture if the patient sustained
a fall or a direct blow to the area; alternative causes of pain here
include prepatellar bursitis, as previously noted. Tenderness
proximal to the patella most commonly represents tendonitis
of the quadriceps or strain of the quadriceps muscle. If a frank
tendon rupture is present, the examiner will clearly feel a palpa-
ble defect (Fig. 7c.10), and in most cases, the patient is unable
to extend the knee actively or lift the leg with it extended.
Tenderness distal to the patella can indicate chronic tendonitis
(Jumpers knee) or an acute tear if a palpable defect is noted
and the patient is unable to extend the knee actively.
The patella itself can also be examined to determine its
mobility by gently moving it from side to side with the knee
extended; normally, the patella should be mobile in extension
and fixed in flexion. Whether this maneuver is painful or not and
whether crepitation is sensed should be carefully noted because
these symptoms may indicate arthritis of the patellofemoral
articulation or patellar instability. The examiner should not be
able to dislocate the patella completely from within the trochlear
groove. Some patients may experience substantial apprehension
during these translational maneuvers, perhaps indicating patellar
instability; in the setting of acute trauma, tenderness along the
medial border of the patella may be secondary to its dislocation.
Generalized pain with patellofemoral compression may indicate
arthritis or early degenerative changes of the cartilage of the
patellofemoral articulation. If the examiner suspects patellar
instability, the Q angle can be assessed also by determining the
angle tendered between a line drawn from the anterior superior
iliac spine and the quadriceps tendon and a second line drawn
across the tibial tubercle and the central axis of the patella.
Calculated with the knee extended and the patient supine, this
value is expected to range from 15 to 20 degrees.
Next, the joint lines are carefully palpated both medially
and laterally; this is most easily accomplished with the patient
supine and the knee flexed approximately 90 degrees. Localized
tenderness along the joint lines may indicate meniscal pathology
Figure 7c.9 Swollen right knee (typical appearance of an effusion).
Figure 7c.10 Palpable defect in the quadriceps tendon, just proximal
to the patella, indicative of a quadriceps tendon rupture; the patient
was unable to extend the knee actively, and surgical repair was required.
or arthritis. The collateral ligaments can also be palpated directly;
tenderness and localized swelling along the medial or lateral
collateral ligament (including the fibular head where the lateral
collateral ligament inserts) can indicate acute rupture or strain.
Range of motion is measured as flexion and extension with
normal values 0 to approximately 135 degrees. Here 0 degrees is
described as full extension, and values of less than that are
referred to as a flexion contracture that is typically associated
with knee arthritis or other long-standing pathology (Fig. 7c.11).
Inability to extend the knee actively can indicate a disruption of
the extensor mechanism (rupture of the quadriceps or patellar
tendon or fracture of the patella) and is referred to as an exten-
sor lag (Fig. 7c.12). Hyperextension of the knee rarely exceeds
10 or 20 degrees and, if asymmetric, may represent cruciate liga-
ment injury or, rarely, neurologic disease. Although uncommon,
some patients may present with a locked knee wherein the leg
is held in mid-flexion and cannot be flexed or extended; most
commonly involving a large meniscal tear or a loose body that
has become incarcerated in the joint, this symptom is associated
often with acute severe pain and muscular guarding.
Various special tests have been developed in an effort to
identify meniscal pathology: A history of acute injury with an
effusion and joint line tenderness or a subacute history of local-
ized joint line pain, recurrent effusions, and mechanical symp-
toms such as locking suggest it as a cause. Most tests that follow
should not be performed in the setting of acute injury because
they not only cause substantial pain but also are relatively non-
specific. The McMurray test is performed by rotating the tibia
internally and externally while simultaneously flexing and extend-
ing the knee with the patient in the supine position (Fig. 7c.13).
10
0
90
130
Figure 7c.11 Flexion-extension of the knee: normal extension,
10 degrees; flexion, 135 to 150 degrees.
Figure 7c.12 Extensor lag is defined as an inability to actively extend
the knee.
B A
Figure 7c.13 McMurray test. The knee is first rotated in full extension (A) and then extended (B).
The examiners fingers are placed at the joint line during this
maneuver, and a palpable sense of locking or clicking, particu-
larly when combined with recreation of the patients symptoms,
suggests a meniscal tear. Although similar, the Apley test is
performed with the patient prone and the knee flexed 90 degrees
(Fig. 7c.14). The foot is rotated internally and externally while
the joint is distracted or compressed; the test is considered
positive if pain is recreated, particularly while the joint is
compressed.
Knee joint stability is tested by various means. As noted
above, in the setting of acute trauma these tests should typically
be deferred because they can be very painful and muscular guard-
ing secondary to pain compromises their sensitivity. Stability of
the lateral and medial collateral ligaments is determined by
applying a lateral or medial moment to the knee while it is flexed
approximately 20 degrees (Fig. 7c.15). Testing is performed in
mid-flexion to avoid a false-negative result, as the geometry of
the joint itself confers some stability when the knee is fully
extended. If a sprain rather than a frank tear has occurred, the
application of these types of forces causes substantial pain without
the examiner sensing frank instability.
Testing the stability of the anterior cruciate ligament can
involve either the anterior drawer test or the Lachman test. An
anterior draw test is performed with the knee in 90 degrees of
flexion while an anterior force is placed on the tibia (Fig. 7c.16);
in the setting of acute trauma this test is particularly susceptible
to a false-negative result because secondary restraints can com-
pensate for a torn anterior cruciate ligament. Reputed to have
higher sensitivity, the Lachman test is performed similarly,
but the knee is held in approximately 30 degrees of flexion.
Figure 7c.14 Apley test. With the patient prone, the knee is flexed and the foot internally and externally rotated (A) with distraction and (B) with
compression.
A B
Figure 7c.15 Lateral stability is tested with the knee in approximately 15 to 20 degrees of flexion (A, medial; B, lateral).
A B
Specifically, the examiner holds the femur in one hand while
applying an anterior force to the tibia with the other. In both
tests, the examiner notes how far forward the tibia moves on
the femur and whether or not there is a firm endpoint when
such forces are applied. A final test to determine anterior cruci-
ate ligament competency is the pivot-shift test; particularly
uncomfortable for patients (and thus subject to false-negative
results secondary to patient guarding), this test is probably
most useful when performed in the anesthetized patient pre-
operatively. Place the patient supine and flex the knee approx-
imately 30 degrees. Internally rotate the foot and apply a valgus
force on the extremity by the placing the opposite hand on the
tibia. The knee is then extended, and if the anterior cruciate
ligament is ruptured, a palpable subluxation of the joint may be
felt as the tibia jumps forward on the femur. Posterior cruciate
ligament stability is tested using the posterior drawer test. Quite
similar to the anterior drawer test, this test includes placing
a posteriorly directed force on the tibia with the knee flexed
90 degrees while the patient is supine; a firm endpoint should
be felt.
IMAGING DIAGNOSIS
Hip
Radiographic examination of the hip should include at least
an anteroposterior (AP) view of the hip and pelvis and a lateral
view of the hip. Oblique or Judet views may be useful when eval-
uating a patient with a suspected or known acetabular fracture,
and pelvic inlet and outlet views are useful in patients with
known or suspected pelvic fractures. Plain radiographs are the
standard technique for evaluation of trauma and arthritis.
Osteoarthritis is characterized by joint space narrowing
(particularly in the superolateral or weight-bearing portion of
the joint), subchondral sclerosis, and osteophyte formation;
subchondral cysts may also be seen. In advanced cases, erosion
of the femoral head or acetabulum can occur. In the earliest
stages of disease, weight-bearing views may be required to detect
subtle joint space narrowing.
Rheumatoid arthritis is characterized by a more symmetric
pattern of joint space narrowing along with periarticular osteope-
nia; osteophytes are rarely seen until the later stages of the
disease when secondary osteoarthritis develops. Seronegative
arthritides (such as ankylosing spondylitis) usually present also
with fusion of the sacroiliac joints, as seen on the pelvic AP view.
Computed tomography is typically reserved for the evalua-
tion of acetabular and pelvic fractures, but it may detect early
degenerative changes. Three-dimensional reconstructions made
from high-resolution computed tomographies can be used for
better understanding of complex hip anatomy such as in hip
dysplasia. Magnetic resonance imaging (MRI) is useful for iden-
tifying early osteonecrosis or avascular necrosis of the hip and
occult fractures and stress fractures that are not visible on plain
radiographs. In the patient with a history of trauma who com-
plains of groin or hip pain and cannot raise the straight leg
or ambulate, an MRI will most rapidly identify a nondisplaced
fracture of the proximal femur. MR images can also detect loose
bodies or pathology of the acetabular labrum; early degenerative
changes also can be identified. Very sensitive but quite non-
specific, nuclear medicine studies such as bone scans are rarely
useful, except for identifying metastatic disease. Although a bone
scan also can identify subtle arthritis, joint inflammation, or
occult fracture, MRI is superior in showing the specific pathology
so that appropriate treatment can be instituted. In the case of
occult fracture, whereas an MRI shows immediate changes, a
bone scan may not be positive for several days.
Knee
Routine radiographs of the knee include standing AP, lateral,
and patellar (merchant or sunrise) views. Standing AP radio-
graphs are recommended to assist in identifying subtle joint
space narrowing and determining overall alignment (normally
7 degrees of valgus). Typically performed with the knee in
30 degrees of flexion, the lateral view is nonweight bearing.
Additional views that may be helpful include a weight-bearing AP
view with the knee flexed 45 to 60 degrees. Commonly referred
to as a skiers view, this radiograph often identifies more subtle
joint space narrowing as the posterior aspect of the femoral
condyle is imaged.
Radiographic markers of osteoarthritis include joint space
narrowing, subchondral sclerosis, and osteophyte formation.
Radiographic changes may affect the medial tibiofemoral, lateral
tibiofemoral, or patellofemoral compartments. The most common
pattern is a varus deformity with the most severe radiographic
changes affecting the medial compartment, although patients
can develop a valgus deformity or have arthritis that affects
predominantly the patellofemoral joint. Inflammatory arthritis
generally causes a more symmetric pattern of joint space loss
with periarticular osteopenia and often a valgus deformity. Plain
radiographs can be reviewed not only for bony pathology such
as arthritis or fracture but also for soft tissue pathology because
symptoms such as a large effusion are often identifiable
radiographically. Stippled calcifications seen in the area of the
joint space may represent chondrocalcinosis or pseudo-gout.
Figure 7c.16 Anterior drawer test to detect cruciate ligament injury.
A high riding patella or patella alta may indicate rupture of the
patellar tendon. MRI is used as a secondary test to identify pathol-
ogy of the ligaments and menisci; more subtle damage to the car-
tilaginous surfaces can be recognized also as can processes such as
osteonecrosis. Although bone scans are used occasionally to iden-
tify early degenerative changes when plain radiographs are nega-
tive, MRI is often both more sensitive and certainly more specific.
ARTHROSCOPY
In the patient with persistent complaints of pain or instability in
the face of plain radiographs and advanced imaging studies,
arthroscopic examination of the knee can be used for diagnostic
purposes to directly view its anatomic structures. Although tests
such as MRI are quite sensitive, false-negative results can occur.
Similarly, arthroscopy of the hip is used occasionally in situa-
tions where subtle pathology of the labrum or cartilage is sus-
pected that may be unrecognized with other tests. The greatest
strength of arthroscopy is the ability to both diagnose and treat
at the same time.
SUMMARY
Clinical evaluation of the hip and knee often allows the physician
to make a diagnosis and plan for treatment. Imaging is some-
times a necessary complement but should always be evaluated
in light of the clinical findings. Advanced imaging such as com-
puted tomography and MRI are rarely necessary and should
not be used for screening purposes, because the yield is low and
false positive findings are not uncommon.
Chapter 7c Summary 297
Hip and Knee:
Treatment Options
James B. Talmage
Work-related problems in the lower limb are quite different from
those in the upper limb. Physicians frequently see patients with
occupational illnesses of the upper limb, where no major traumatic
event has occurred, and the patients complaints are believed to
be related to repetitively performing the same task(s). In the
lower limb, these overuse disorders are distinctly uncommon.
Sports medicine physicians see overuse hip and knee injuries,
but these are very uncommon in workers compensation patients.
The lower limb seems to be built with more reserve capacity for
activity than is present in the upper limb. Thus, unlike when
treating upper limb disorders, physicians rarely treat lower limb
disorders and then have to ponder the wisdom of returning
workers to jobs in which the repetitive performance of simple
activities is alleged to have initiated the overuse illness. Most hip
and knee problems that come to the attention of physicians are
either gradually progressive age-appropriate degeneration (e.g.,
osteoarthritis), acute traumatic injuries (e.g., knee meniscal tear),
or rheumatologic illness (e.g., acute gout or rheumatoid arthritis).
Treatment of these hip and knee problems is the same for
those patients in the workers compensation system (e.g., acute
knee meniscal tear at work) as it is for those who have the same
problem but are not in the workers compensation system. The
results may not be as good. A recent meta-analysis showed that
in 175 of 205 published studies, the results of surgical treatment
of compensation patients were not as good as the results of treating
the same condition with the same surgery in noncompensation
patients.
7
The pooled odds ratio for an unsatisfactory outcome
in compensated patients compared with noncompensated
patients was 3.79 (95% confidence interval, 3.28-4.37). Decisions
on return to work require consideration of the nature of the
condition. Acute injuries generally show progressive improve-
ment with time and treatment, whereas progressive diseases like
osteoarthritis and rheumatoid arthritis may show progressive
deterioration requiring job modification or career changes.
THE HIP
Hip problems in workers are uncommon and much less commonly
seen than knee problems. For example, the American College of
Occupational and Environmental Medicines Occupational
Medicine Practice Guidelines, 2nd edition, contains a chapter on
every part of the musculoskeletal system except for the hip. The
material in the preceding chapter on diagnosis is not repeated,
and the reader is referred to that chapter for details. A few of
the more common disorders affecting the hip are discussed in
terms of treatment and work implications.
Hip fractures are major acute injuries, generally from sig-
nificant falls (Fig. 7d.1). Hip fractures are usually treated with
surgical internal fixation or prosthetic replacement. For example,
significantly displaced femoral neck fractures are frequently
treated with prosthetic replacement of the proximal femur due
to the high probability of the complication of avascular necrosis
of the femoral head, whereas nondisplaced femoral neck frac-
tures are usually treated with internal fixation for stabilization
while the fracture heals. The orthopedic surgeon determines,
based on the type of fracture and the type of surgery performed,
when weight bearing on the affected limb is permissible. Until
weight bearing is permitted, a worker can only do work in a
sitting position. Ambulation at work would require crutches
or a wheelchair and at least temporary access to handicapped
parking. Periods of leg elevation may be required for preven-
tion of thrombophlebitis. Workers with hip fractures may be
using narcotic pain medication for several weeks or months.
Company policies on work while using medications need to
be considered.
Hip arthritis may be a cause for hip pain with work activity
(Fig. 7d.2). Osteoarthritis is much more common than knee
arthritis. It increases in prevalence with age. Other than in farm-
ers, epidemiologic studies have not associated hip osteoarthritis
with work activity, so workers can continue to safely work
despite osteoarthritis of the hip.
17
The paradox of osteoarthritis
in the lower limbs is those who get osteoarthritis of the hip do
not usually get osteoarthritis of the knee, and those who get
osteoarthritis in the knee do not usually get it in the hip; neither
group gets osteoarthritis of the ankle, and yet each joint carries
the same body the same number of steps. Simple overuse or
wear and tear does not explain osteoarthritis. Ten to 20% of
osteoarthritis patients present with arthritis in both the hips and
the knees, but these patients also have multiple other joints
involved (spine, shoulders, wrists, hands, and/or feet), suggesting
a genetic disorder.
7
Nonoperative treatment includes trials of nonsteroidal anti-
inflammatory drugs (NSAIDs) and a cane in the contralateral
hand. No NSAID has proven to be superior, and physicians
frequently prescribe several in serial trials, looking for the
NSAID that gives the best relief and fewest side effects in the
individual patient. The COX-2specific NSAIDs have not been
shown to provide better pain relief that the older traditional
mixed COX-1 and COX-2 NSAIDs. The COX-2specific drugs
are suspected of having an association with myocardial infarction
and stroke and are being prescribed less frequently. Weight reduc-
tion is frequently recommended on biomechanical principles but
is rarely achieved. Dietary supplementation with glucosamine
and chondroitin sulfate can be tried. These nutraceuticals are
safe because they are compounds found in the human diet. They
may decrease symptoms in osteoarthritis, although their onset
of action is slow (several months). Whether they have a disease-
modifying affect is being debated.
11,16
Glucosamine has not been
shown to raise fasting blood glucose levels in diabetics.
Severe hip pain is usually treated with total hip replacement.
After hip replacement surgery, the surgeon determines when
full weight bearing can occur. Cemented hip replacements are
C HA P T E R
7d
Chapter 7d Hip and knee: treatment options 300
A
B
D C
Figure 7d.1 (A) Plain radiographs of a 65-year-old woman who complained of severe pain after a fall. No evidence of fracture is seen on
the initial film (arrow). (B) Magnetic resonance imaging of the pelvis. T1-weighted spin echo and (C) STIR images demonstrate focal bone marrow
edema (arrows) in the femoral neck and a difference in intensity, indicating the presence of a nondisplaced femoral neck fracture. (D) Bone scan
shows intense focal uptake at the site of the fracture (arrow). Intense diffuse uptake in the contralateral hip is due to osteoarthritis. STIR, short
inversion time inversion recovery.
inherently stable, and full weight bearing can be permitted almost
immediately. Noncemented hip replacements require time for
bone to grow into the porous coating of the implant or for the
patient to heal to the implant before full weight bearing can
be permitted. After hip replacement, permanent restrictions against
running, jumping, full squatting, kneeling, crawling, heavy lifting,
and carrying are common to prevent loosening and dislocation
of the prosthetic components.
Avascular necrosis of the hip (osteonecrosis) is an uncommon
problem (Fig. 7d.3). It may occur as a complication of femoral
neck fracture or hip dislocation. It is seen without a history of
trauma in patients with a history of systemic corticosteroid use,
alcoholism, and as an idiopathic condition. In its early stages it
is treated much like hip osteoarthritis with NSAIDs and a cane
or crutches. If femoral head collapse has not yet occurred when
the condition is recognized, nonweight-bearing ambulation
with crutches may be recommended. In these early cases, bone
grafting surgery is frequently tried. Late cases with femoral head
collapse and severe pain are treated with hip replacement.
Trochanteric bursitis is the most common bursitis about the hip.
This is painful but not serious, because no significant consequences
result from continued activity despite pain. Nonoperative treat-
ments include NSAIDs, stretching, and strengthening exercises
frequently initially under the supervision of a physical therapist.
For refractory cases a corticosteroid injection into the region of
the bursa may be helpful. Surgery is rarely indicated. A tempo-
rary period of reduced work activity may be useful, but it should
not exceed 6 weeks.
Hip sprains and strains are uncommon in the workplace.
They must be differentiated from inguinal and femoral hernias.
They usually result from significant falls, because few jobs include
running or jumping activities likely to cause a hip strain or sprain.
Heavy lifting rarely injures anything about the hip. Most sprains
and strains recover in 6 weeks or less. Nonoperative treatment
includes pain control and rehabilitation through stretching and
strengthening exercises. Those that persist are usually evaluated
by magnetic resonance imaging (MRI), looking for the unusual
bone bruise, early avascular necrosis, transient osteoporosis of
the hip, bursitis about a deep hip bursa (of which there are 13),
or an acetabular labrum tear. Tears of the labrum do not always
visualize on MRI, however, and hip arthroscopy may be neces-
sary to exclude or to treat this diagnosis. For simple sprains and
strains, a temporary period of reduced work activity may be help-
ful, but it should not exceed 6 weeks.
Sprains and strains of the hip region, like those of other joint
regions, heal in a known sequence. Muscles, ligaments, and ten-
dons begin with an inflammatory phase of healing, progress to a
synthesis phase, and finish with a remodeling phase. Although it
may decrease pain, antiinflammatory medication does not speed
up healing of muscles, ligaments, or tendons.
6
Inflammation is
a necessary part of tissue healing. Muscle relaxants are really
centrally acting minor tranquilizers, and sedation accounts for
their muscle relaxation. If a patient is not sleeping well, one
dose a day at bedtime may improve his or her sleep pattern.
Opioid analgesics, on occasion, are used for severe acute
pain symptoms. Opioid analgesics act primarily by binding to
opiate receptors in the central nervous system. They have poten-
tial problems of tolerance, dependence, addiction, and illicit
use/diversion with long-term administration. Even short-term use
of these medications should be undertaken with caution because
potential problems with demotivation, early reactive hyperalge-
sia, and early dependency can occur in a select group of patients.
Although more potent than NSAIDs and acetaminophen, in
two of three clinical trials narcotic analgesics were not found
to be more effective. The dosage schedule should be defined
(not PRN) and use limited to patients whose pain is unrespon-
sive to alternative medications.
10
Physical agents including ultrasound, electrical stimulation,
and heat and cold have been used to supposedly speed healing
by increasing circulation and decreasing inflammation while
reducing pain. These passive modalities do not appear to have
any effect on clinical outcomes. No single modality has been
shown to be superior to others for relief of musculoskeletal pain.
Prolonged use of these passive modalities should be discouraged.
Short-term use (1 to 3 weeks) of physical modalities may be
appropriate for an acute musculoskeletal problem or a flare-up
of a chronic condition, if they facilitate participation in active
rehabilitative exercise.
6
THE KNEE
Acute knee injuries are common, although most are not work
place injuries. Overuse syndromes about the knee are mainly
a sports medicine problem and not a workers compensation
problem. For example, the American College of Occupational
and Environmental Medicines Occupational Medicine Practice
Guidelines, 2d edition, discusses the treatment of many condi-
tions affecting the knee, none of which is occupational overuse.
Meniscal injuries are common (Fig. 7d.4). Small stable menis-
cal tears may produce only occasional tolerable symptoms
with heavier activity. For these minor tears, patients may be
content with intermittent use of NSAIDs and a home strength-
ening exercise program. A single intraarticular corticosteroid
injection is sometimes given to decrease acute pain and effusion,
hoping to permit earlier rehabilitative exercise. For patients
Chapter 7d The knee 301
Figure 7d.2 Severe osteoarthritis of the left hip with cystic changes
in both the acetabulum and femoral head (arrow) in a 59-year-old
school teacher. The contralateral hip was treated with a cementless
total hip arthroplasty.
with persisting major mechanical symptoms, arthroscopic partial
meniscectomy is the now traditional treatment. For young
patients with large peripheral tears (near the joint capsule where
the meniscus still has a blood supply) that are discovered early,
meniscal repair instead of meniscectomy is sometimes performed.
If the meniscal tear is repaired, and if it heals, hopefully knee
function will be normal, and the late posttraumatic arthritis that
usually develops in knees after meniscectomy can be prevented.
Long-term studies on this procedure are in progress. For the
young person without age-related osteoarthritis who sustains a
large symptomatic meniscal tear, transplantation of a cadaveric
meniscus is occasionally performed. More often this is per-
formed in the young patient without significant arthritis change
who remains symptomatic after total meniscectomy and who
does not have significant knee deformity or instability.
12
Patients with isolated meniscal injuries can almost always
return to the job they were doing before the injury. Arthroscopic
partial meniscectomy usually permits return to even heavy
D C
B A
Figure 7d.3 (A) Severe avascular necrosis of the femoral head in a 35-year-old alcohol abuser. Note the incongruity of the femoral head
with collapse (arrow). (B) Frog-leg lateral demonstrates severe collapse of the superior portion of the femoral head (arrows). (C) Magnetic
resonance imaging of the pelvis. T1-weighted and T2-weighted (D) spin-echo images demonstrate the extent of osteonecrosis in the femoral head.
work in 6 weeks (or at most 12 weeks).
13
Patients with meniscal
repair or meniscal transplantation require longer periods of
activity restriction with emphasis on avoiding extreme flexion
and twisting.
Knee ligament injuries are sprains (Figs. 7d.5 and 7d.6).
Isolated grade 1 and grade 2 sprains typically heal in 6 weeks
and leave no sequela. Partial injuries to a cruciate ligament are
sometimes treated with temporary protective bracing in addition to
activity restriction to minimize the chance of reinjury. Complete
or grade 3 injuries to the medical collateral ligament are usually
treated nonoperatively. Grade 3 injuries to the lateral collateral
ligament may be treated with primary surgical repair. Grade
3 injuries to a cruciate ligament do not heal and are not amenable
to primary repair. A period of rehabilitative exercise after injury
permits a decision as to whether the residual symptoms can be
tolerated with NSAIDs, quadriceps and hamstring strengthening
exercise, and bracing. If not, reconstruction of the involved
cruciate ligament is the surgical option.
B A
Figure 7d.4 (A) Magnetic resonance imaging (MRI) of a normal meniscus appears black (arrows) in a proton-density-weighted image, as it does
in this case. (B) MRI of a torn meniscus. The posterior horn tear appears as a high-intensity white line or band (arrows).
B A
Figure 7d.5 (A) T2-weighted magnetic resonance imaging (MRI) of a normal anterior cruciate ligament (ACL) that has a low-intensity
(black edge) straight anterior margin (arrows). The posteroinferior edge of a normal ACL is variable in appearance; it is high in intensity in this
case. (B) T2-weighted MRI of a torn ACL. Tissue in the expected region of the ACL is high in signal and disorganized, indicating a tear. Note the
frayed ends of the torn ligament (arrows).
If residual instability is present, and especially if instability is
present in two planes (both varus-valgus and anterior-posterior
instability), posttraumatic arthritis generally develops at an accele-
rated rate. Bracing and permanent work activity restriction or a
career change may be indicated if the patient usually performs
heavy work.
Osteoarthritis of the knee is very common. It increases
in prevalence with age, and it is associated with family history,
knee varus or valgus deformity, obesity, prior intraarticular frac-
ture, and prior significant meniscus or ligamentous injury. At
present, there are no conclusive data on the association of knee
osteoarthritis and patients prior activity levels.
3
Osteoarthritis of
the knee is not a simple wear and tear problem.
Nonoperative treatments
1
of knee arthritis include NSAIDs,
use of a cane, and usually weight reduction (again, frequently
prescribed but rarely accomplished). Physical therapy consulta-
tion for training in quadriceps and hamstring strengthening
may help significantly with symptoms, because the developing
arthritis has frequently resulted in favoring the symptomatic
knee and thus quadriceps and hamstring weakness from disuse.
15
This exercise prescription does not result in further wearing
out of the knee, because osteoarthritis is not a simple wear and
tear problem. Unlike automobile tires, knees do not have a fixed
number of miles they can travel.
For patients with a significant knee varus deformity (bow legs),
lateral wedge shoe insoles decrease the external varus moment
and the estimated medial compartment load, resulting some-
times in pain improvement, especially in early stage arthritis.
An unloader brace, which applies a varus or valgus moment to
reduce force transmission in the most involved knee compart-
ment (medial or lateral), can be tried in an active patient with
isolated unicompartmental disease. Most patients discontinue
brace use as the arthritis progresses. Work activity modification
may be necessary as the arthritis progresses.
As in hip osteoarthritis, glucosamine and chondroitin
may be tried, and some patients improve symptomatically.
11
Acetaminophen (paracetamol in Europe) for many arthritis
patients gives acceptable osteoarthritis pain relief with a better
side effect or safety profile, and many reviewers recommend this
drug be tried before NSAIDs are used.
5,19,20
If symptoms are more severe, injection therapy is frequently
used. Intraarticular corticosteroid injections may significantly
decrease pain and effusion and may be repeated as often as
every 3 months without documented worsening of the arthritis
or other adverse effects.
2,4
Intraarticular hyaluronic acid injection
or viscous supplementation may also be tried. It is U.S. Food
and Drug Administration approved as a series of three injections;
however, it is much more expensive than simple corticosteroid
injection, and its efficacy is controversial.
8
As in hip osteoarthritis, when pain and disease become severe,
surgical treatment is used. Arthroscopic debridement of the
degenerative knee was performed in the past, although since the
publication of a randomized controlled trial
14
that showed no
benefit over placebo arthroscopy, this surgery is rarely performed.
Arthroscopy is still indicated for comorbid osteoarthritis and
significant mechanical pathology, like a major meniscal tear or a
loose body.
For early varus deformity with medial compartment arthritis
or for early valgus deformity with lateral compartment arthri-
tis, if the other compartment is still relatively normal, a weight-
transferring osteotomy of the proximal tibia is sometimes
performed. Varus deformities are usually treated by lateral closing
wedge osteotomy and valgus deformities by medial closing wedge
osteotomy (Fig. 7d.7). The ideal patient for osteotomy has single-
compartment arthritis, ligamentous stability, and is young and
physically active.
13
Absolute contraindications include inflam-
matory arthritis, severe tricompartmental disease, a flexion arc
of 90 degrees or less, marked tibiofemoral subluxation, and
A B
Figure 7d.6 (A) T2-weighted magnetic resonance imaging (MRI) of a normal posterior cruciate ligament (PCL) in a 25-year-old man. The ligament
(arrows) is normally black, as it is in this case. (B) MRI, torn PCL. The bright appearance of the proximal end of the ligament and its discontinuity
(arrows) indicates a tear at its attachment to the femur.
previous meniscectomy in the contralateral compartment.
Relative contraindications include age older than 60 years,
patellofemoral arthritis, collateral ligament insufficiency, lateral
tibial subluxation, or a varus deformity more than 10 degrees.
Once the osteotomy (broken tibia) has healed, activity restric-
tions may not be needed. Osteoarthritis is a progressive disease,
so results deteriorate with time, and up to 40% of patients
undergo knee replacement in 5 years and 50% in 10 years.
9
For patients with severe arthritis and pain who are not candi-
dates for osteotomy, unicompartmental knee replacement or total
knee replacement are the surgical options (Figs. 7d.8 and 7d.9).
Current knee replacement designs can be expected to last at least
15 years before wear requires revision.
14
As in hip replacement,
cemented knee replacements are immediately stable, whereas
noncemented units require time for the patient to heal to the
implant before full weight bearing is allowed. Rehabilitation
after knee replacement is slower than after hip replacement.
After successful replacement arthroplasty, the worker requires
permanent restrictions prohibiting jumping, heavy lifting, and
so forth.
Knee tendonitis is an occasional problem, although again is
much more frequently seen in a sports medicine practice than in an
occupational medicine practice. It may involve the quadriceps
A B
Figure 7d.8 (A) A severe varus deformity in an 8-year-old girl with partial loss of the medial tibial plateau (arrow). (B) Total knee arthroplasty
required a bone graft fixed with screws on the medial side to support the tibial plate (arrow).
Figure 7d.7 Bilateral varus deformities with medial joint arthritis in a
41-year-old woman treated with a high tibial osteotomy on the left side
to correct her varus alignment.
tendon, the patellar tendon, the iliotibial band, the popliteus
tendon, or the medial hamstring tendon insertions (pes anserine
bursitis). Treatment is usually symptomatic with a brief period of
activity restriction, NSAIDs, and stretching and strengthening
exercises. There is very little quality evidence on the role of phys-
ical therapy for knee tendinitis syndromes.
1
For the patellar
tendon, use of a strap orthosis may provide partial symptom
relief. For refractory cases a corticosteroid injection may be used
(but not for the quadriceps or patellar tendons because of the
possibility of steroid induced tendon weakness predisposing to
tendon rupture). In athletes, a shoe orthotic to alter knee
mechanics is sometimes helpful. Surgery is used only for serious
complications like complete rupture of a quadriceps or patellar
tendon.
Patellofemoral pain is a frequent complaint and is some-
what like chronic headache and chronic low back pain in that
the findings in patients with anterior knee pain are usually non-
specific and commonly seen in asymptomatic individuals.
Anterior knee pain in patients with obvious patellar malalignment
or patellar instability (subluxations) can be rationally treated
surgically, although with less than ideal results in many cases.
Patients with anterior knee pain without obvious patellar
malalignment or instability are challenging. In many patients
the pain is attributed to chondromalacia of the patella, although
arthroscopy studies have shown that the patella has normal
cartilage in many of these cases.
10
A patellar plica is a fold of
synovium present in embryologic life that does not always resorb
in childhood. In some adults it is postulated to be a cause of
anterior knee pain. However, results from excising the plica
arthroscopically are variable, and the persisting plica was not
considered to be a source of symptoms when knee surgery was
by open arthrotomy. Cynics believe that the plica is implicated
so that surgeons can charge more (therapeutic arthroscopy
is reimbursed at a higher level than a negative diagnostic
arthroscopy).
Other than for obvious patellar malalignment or instability,
the treatment for anterior nonspecific knee pain is usually non-
operative. NSAIDs are tried, although they may be ineffective.
Physical modalities have not been proven to be effective treat-
ment.
1
Aerobic conditioning and quadriceps and hamstring
stretching and strengthening exercises are usually tried. Closed-
chain knee extension strengthening exercises between 0 and
30 degrees of flexion put the least compression load on the patella
and may be tolerated and thus performed. Surgical debridement
(patellar chondroplasty) has variable to disappointing results.
Like the patient with chronic low back pain, the patient
with chronic anterior knee pain without objective findings is at
times a problem in the workplace. There is no risk of serious con-
sequences if the patient/worker remains active at work despite
pain. The crucial issue is the patients tolerance for workplace
symptoms, and in the absence of major objective findings, there
is not usually physician agreement on the appropriateness of
advising employers or patients to decrease the job demands on
the patient.
18
REFERENCES
1. Archibeck MJ, Ayers DC, Berger RA, et al: Knee reconstruction. In KJ Koval, ed:
Orthopaedic knowledge update 7. Rosemont, IL, 2002, American Academy of
2. Arroll B, Goodyear-Smith F: Corticosteroid injections of osteoarthritis of the knee:
meta-analysis. BMJ 328:869-873, 2004.
3. Clyman B: Sports, exercise, and arthritis. Bull Rheum Dis 50(6):1-3, 2001.
B A
Figure 7d.9 (A) Bilateral degenerative joint disease in a 56-year-old woman rheumatoid patient. Note the complete loss of joint space, severe
osteopenia, and lack of osteophytes typical of rheumatoid arthritis. (B) Bilateral total knee arthroplasties were cemented in place because of
poor bone quality in this patient.
4. Cole BJ, Schumacher HR Jr: Injectable corticosteroids in modern practice.
JAAOS 13(1):37-46, 2005.
5. Courtney P, Doherty M: Key questions concerning paracetamol and NSAIDs for
osteoarthritis. Ann Rheum Dis 61:767-773, 2002.
6. Dahners LE, Mullins BH: Effects of nonsteroidal anti-inflammatory drugs on bone
formation and soft-tissue healing. JAAOS 12(3):139-143, 2004.
7. Harris I, Mulford J, Solomon M, et al: Association between compensation status and
outcome after surgery. JAMA 293:1644-1652, 2005.
8. Lo GH, LaValley M, McAlindon T, et al: Intra-articular hyaluronic acid in treatment of
knee osteoarthritis: a meta-analysis. JAMA 290(23):3115-3121, 2003.
9. Lonner JH: Clinical crossroads: a 57 year-old man with osteoarthritis of the knee.
JAMA 289(8):1014-1025, 2003.
10. Mayer TG, Press J: Musculoskeletal rehabilitation. In AR Vaccaro, ed: Orthopaedic
knowledge update 8. Rosemont, IL, 2005, American Academy of Orthopaedic
Surgeons, pp. 655-660.
11. McAlindon T: Glucosamine and chondroitin for osteoarthritis? Bull Rheum Dis
50(7):1-4, 2001.
12. McCarty EC, Spindler KP, Bartz R: Knee and leg: soft-tissue trauma. In AR Vaccaro,
ed: Orthopaedic knowledge update 8. Rosemont, IL, 2005, American Academy of
13. http://www.mdainternet.com/V5/mdaTopics.aspx. Accessed 05/28/05.
14. Mosely JB, OMalley K, Petersen NJ, et al: A controlled trial of arthroscopic surgery
for osteoarthritis of the knee. N Engl J Med 347(2):81-88, 2002.
15. Philadelphia panel evidence-based clinical practice guidelines on selected
rehabilitative interventions for knee pain. Phys Ther 81(10):1675-1700, 2001.
16. Richy F, Bruyere O, Ethgen O, et al: Structural and symptomatic efficacy of
glucosamine and chondroitin in knee osteoarthritis: a comprehensive
meta-analysis. Arch Intern Med 163:1514-1522, 2003.
17. Sherrer YS: Working with common rheumatologic disorders. In JB Talmage,
JM Melhorn, eds. A physicians guide to return to work. Chicago, 2005, AMA Press.
18. Talmage JB, Melhorn JM: How to think about work ability and work restrictions: risk,
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return to work. Chicago, 2005, AMA Press.
19. Zhang W, Doherty M, Arden N, et al: EULAR evidence based recommendations for
the management of hip osteoarthritis: report of a task force of the EULAR standing
committee for international clinical studies including therapeutics (ESCISIT). Ann
Rheum Dis 64(5):669-681, 2005.
20. Zhang W, Jones A, Doherty M: Does paracetamol (acetaminophen) reduce the pain
of osteoarthritis? A meta-analysis of randomized controlled trials. Ann Rheum Dis
63:901-907, 2004.
Workplace-Related Lower
Extremity Disorders:
Workplace Adaptations
with Case Studies
Amit Bhattacharya, Daniel J. Habes, and James A. Dewees
MAGNITUDE OF THE PROBLEM
Work-related lower extremity
musculoskeletal disorders
A significant amount of research has been performed in the area
of cumulative trauma disorders of the upper extremity and
low back pain of occupational origin.
127
Although studies on this
topic are important enough to warrant further investigation, it
is becoming more important to address the need to evaluate the
lower extremity cumulative trauma syndrome. According to
the Bureau of Labor Statistics, there were 1.4 million injuries
and illnesses in private industry that required days away from
work in 2002. Of these, 488,000 (34%) were musculoskeletal
disorders, defined as injuries or disorders of the muscles, nerves,
tendons, joints, cartilage, and spinal disks. Twenty-one percent
of these musculoskeletal disorders occurred in manufacturing
and about 9% occurred in construction. The back accounts for
the greatest number of occupational injuries and illnesses, but
reports for the upper extremity (hand, finger, wrist) and lower
extremity (knee, foot, toe) are comparable with each other for
both total injuries and illnesses (Fig. 7e.1A) and for muscu-
loskeletal disorders only (Fig. 7e.1B). Moreover, the severity
of injuries and illnesses to the lower extremity exceeds that for
both the upper extremity and back, trailing only that of the shoul-
der (Fig. 7e.1C). For the years 2000-2002 the median number of
days away from work for back, upper extremity, lower extremity,
and shoulder injuries and illnesses has averaged 6, 6, 8, and
12 days, respectively.
According to 2002 Bureau of Labor Statistics data, the services
industry, which includes health care and social assistance,
accounted for more lower extremity musculoskeletal disorders
with days away from work than any other broad industry cate-
gory (11,092). Manufacturing (5759) and transportation and pub-
lic utilities (5668) were next, with about half the number of lower
extremity musculoskeletal disorders with days away from work as
services but higher severity rates with median days away from
work of 11 and 15 days, respectively. Construction, which was
fifth on the list of industries having lost work-day lower extrem-
ity musculoskeletal disorders (4748), also experienced more
severe cases than services, having a median number of days
C HA P T E R
7e
lost of 15. Furthermore, in the construction industry, muscu-
loskeletal disorders involving the knee resulted in a median of
29 lost work days, a severity higher for the knee than any of the
industry groups having more total lower extremity musculoskeletal
disorders.
Despite these facts from the Bureau of Labor Statistics, scien-
tific studies and journal articles found in the literature predom-
inantly address the upper extremity. Entering the key words
upper extremity musculoskeletal disorders and lower extremity
musculoskeletal disorders into a popular search engine yields
877 and 20 hits, respectively.
There is additional justification for this new emphasis area
based on the following facts: The working population is aging,
and because age-induced muscle strength impairment affects
the lower extremity and the upper extremity, it stands to reason
that tasks requiring repetitive and sustained use of lower limbs
detrimentally affect this part of the body. In contrast to the
upper extremity, the lower limbs are under sustained static and
dynamic loading due to weight bearing. When a person is
simply standing upright, the lower extremity joints (such as
ankle, knee, and hip joints) experience sustained biomechanical
loading. These loadings become significantly high and repetitive
(2 to 20 times the body weight) during simple walking and run-
ning.
16,43
With an aging musculoskeletal system, such high repet-
itive loading may detrimentally affect the health of the joints.
Furthermore, with the aging process, it is well established
that in the general population the incidence of musculoskeletal
disorders such as osteoarthritic knee is very high. It is estimated
that over 80% of people over the age of 55 have a clinically diag-
nosed osteoarthritic condition.
64,138
In the aged population the
joint complaints of the lower extremities are more frequent
than that of the upper extremities.
11
There is sufficient evidence
in the literature
4
that osteoarthritis causes more absenteeism than
any other joint trauma. Therefore, a worker population chosen
from such a sample is at a high risk of developing significant
musculoskeletal disorders of the lower extremity.
Keeping in mind the changing demographics of the aging
work force and the fact that lower extremity injuries account for
about 20% of all compensable injuries, it is rather important that
we further study this particular cumulative trauma. In particular,
because most of the industrial tasks require some amount of
sustained standing, it places excessive loading on the already
traumatized lower extremity joints due to aging. Furthermore,
jobs requiring excessive kneeling and walking further traumatize
the aging lower extremity joints.
A review of the literature indicates that a variety of occupa-
tions that require excessive use of the lower extremities shows a
high incidence of musculoskeletal disorders. For example,
osteoarthritic/arthritic and other types of musculoskeletal con-
ditions of the knee, ankle, and hip have been documented in
carpet layers, ballet dancers, housemaids, miners, and construc-
tion workers.
13,24,26,38,63,66,69,105,107,108,122
Similar findings of lower
extremity trauma have been documented in people involved in
professional athletics such as soccer, football, bicycling, and
running.
8,24,60,101
Coggon et al
33
concluded that there is strong evidence
for occupational osteoarthritis from prolonged kneeling and
squatting but reported that obesity may be a factor in such
workers. A study by Lindberg and Montgomery
67
reported that
Chapter 7e Workplace-related lower extremity disorders 310
2000
700000
600000
500000
400000
300000
200000
100000
0
N
u
m
b
e
r

o
f

i
n
j
u
r
i
e
s
2001
Year
2002
Trunk
Upper Ext
Lower Ext
A
2000
450000
400000
350000
300000
250000
200000
150000
100000
50000
0
N
u
m
b
e
r

o
f

M
S
K
2001
Year
2002
Trunk
Upper Ext
Lower Ext
B
2000
P
e
r
c
e
n
t
a
g
e
2001
Year
2002
Trunk
Upper Ext
Lower Ext
30
25
20
15
10
5
0
C
Figure 7e.1 (A) Number of nonfatal occupational injuries and illnesses with days away from work for select parts of the body, years 2000-2002.
(B) Number of musculoskeletal disorders (MSK) involving days away from work for selected body parts, years 2000-2002. (C) Percentage of
nonfatal injuries and illnesses with days away from work exceeding 30 days for selected body parts, years 2000-2002.
osteoarthritic knee conditions in 322 shipyard workers (average
age, 66 years) were significantly related to long-term (30 years)
exposure to heavy labor rather than age. An epidemiologic
study
106
of 342 chain saw operators and 277 rock drill operators
indicated that these workers showed not only classic cases of
vibration white finger disorders but symptoms of numbness and
coldness in the legs as well. The workers with the most frequent
symptom were older and had longer exposures to vibration. The
results imply vibration-induced disturbance of circulation of the
lower limbs. Earlier studies
14,139
showed that whole body vibra-
tion can cause modification of the cardiovascular system relevant
for the lower extremities. Such disorders do not occur suddenly;
rather, it is the long-term insult by the externally applied forces
that gives rise to microtrauma of the biologic issues in question.
The human body undergoes microtrauma on a daily basis
from performing routine tasks such as walking, running, and
climbing stairs. For normal tissue, exposure to such a low level
of force causes gradual replacement of microscopically injured
tissues with new ones. However, when the activities become
more stressful and repetitive and the loading envelope reaches a
certain limit, the biologic system no longer is able to respond by
regeneration, and the result is pathologic conditions. Furthermore,
the onset of such pathologic response is highly dependent on the
existing health status of the tissue. For example, with the aging
process, the susceptibility of injury to tissues under loading to
externally applied forces is high. Middle-aged or elderly workers
who are exposed to repetitive loading of certain parts of their
bodies may be highly susceptible to injury due to declining
health status in their tissue properties and not being able to
sustain the insult caused by the external loading.
Case study of carpet layers
Lower extremity trauma in carpet installers The concept
of microtrauma induced by repetitive loading as described above
is used for analyzing the job of carpet layers in our laboratory.
This section presents the approach involving ergonomic/
biomechanical principles to better understand, characterize, and
monitor lower extremity trauma experienced by these workers
and to provide some solutions to help minimize this trauma.
There are occupations (such as carpet laying) where knee
injury claims have been significantly higher than knee injury
claims from all occupations. Morbidity data indicate that carpet
installers experience more than 10 times the number of lower
extremity disorders than expected, given the percentage of
these workers in the United States.
117
Although others such as
tile setters, floor layers, drywall installers, cement and concrete
finishers, and carpenters also use their lower extremities in the
performance of their jobs by kneeling, the carpet layers exposure
to mechanical loading to the knee is not limited to the task of
kneeling. A comparison of knee disorders among essentially
equal numbers of carpet and floor layers to painters indicated
that the former group reported more knee pain, knee accidents,
and treatment regimens for the knees than the latter group.
Osteophytes of the patella were more common among the
carpet and floor layers as measured by radiographic changes.
55
Ultrasonography performed by these same authors found thick-
ening of the prepatellar or superficial infrapatellar bursa in
49% of carpet installers versus 7% of house painters.
54
The carpet layers further heighten the trauma to their knees
by impacting on a carpet stretching device called a knee-kicker
at a rate of about 140 kicks per hour with impact peak forces
averaging around 3000 N
15
(Fig. 7e.2A). Similar research found
that seven male carpet layers using a knee-kicker over 39 trials
demonstrated peak forces of 2933 N.
128
In general, the carpet
installation task requires use of awkward body posture, high
impact forces to the knees, high acceleration of lower legs, and
repetition that is biomechanically demanding and, therefore,
provides reasons for high risk of knee disorders (Fig. 7e.2, B to D).
The epidemiologic data of high morbidity (107.8) among
carpet layers compared with tile setters and general floor layers
substantiate the fact that these workers are at a relatively high
risk of developing lower extremity musculoskeletal disorders.
117
According to the Industrial Commission of Ohios report,
3
the
percentage of carpet layers knee injury claims was about four
times higher than knee injury claims filed by all other Ohio
workers. In an epidemiologic/medical study of 112 carpet layers,
42 tilers and terrazzo setters, and 243 millwrights and bricklayers,
Thun et al
122
reported that carpet and floor layers have a high
frequency of bursitis, needle aspiration of knee fluid, and skin
infections compared with the other workers in the study. Their
study also showed that the frequency of impacting on the
knee-kicker was the only statistically significant predictor of
bursitis. The act of kneeling was one of several descriptors of
knee aspiration and skin infection of the knee.
The above summary
12,17-19,54,55,68,117,122,128
of existing research
studies on carpet installers clearly indicates a serious knee morbid-
ity problem exists among these workers. The data so far supports
the fact that the knees of these workers are actually traumatized
by their occupation, and the resulting cost of medical expenses,
earning loss, and physical and psychologic suffering compels
us to investigate further monitoring and prevention of such a
disability of the lower extremity.
Biomechanical basis for clinical responses to the carpet
installation task Most of the postures used during the carpet
installation phase of the job of installing carpet pose unusual
biomechanical demands on the musculoskeletal system. In our
previous study with carpet layers,
17
we were able to identify
typical postures that produce either static or dynamic sustained
loading on the lower extremities (in particular, the knee joint).
In Figures 7e.2A and 7e.3, we present examples of typical body
postures that produce sustained static biomechanical loading
of the knee joint. Such kneeling postures are maintained about
75% of the work period. The arrows in Figure 7e.3 indicate the
potential areas of pressure points due to distributed ground reac-
tion forces acting at the interface of the ground and the body.
Because of excessive knee flexion angles and direct ground pres-
sure at the infrapatellar region associated with these postures,
the infrapatellar bursa is susceptible to injuries. This conclusion
agrees with the finding of investigators at the National Institute
for Occupational Safety and Health (NIOSH) who reported
more frequent infrapatellar bursitis than prepatellar bursitis in
this work force.
122
In Figure 7e.3D, a typical posture is shown which describes
the dynamic act of knee-kicking with the suprapatellar region
of the knee. In our previous study
17
we found that most of the
Chapter 7e Magnitude of the problem 311
time (70%) workers were involved in carpet stretching tasks, using
the knee-kicker to stretch the carpet. The knee-kicking motion
required vigorous and quick extension and subsequent flexion of
the knee joint as the carpet stretching tool was struck. Therefore,
this movement of the leg and the direct impact on the knee-
kicker with the knee potentially exposes the bursae (fluid-filled
sacs whose function is to reduce friction and distribute stress)
located anterior and posterior to the patella to trauma (Fig. 7e.4).
The epidemiologic/medical evaluation study on carpet layers
by Thun et al
122
concluded that only the use of the knee-kicker
predicted the occurrence of bursitis and to some extent knee
tapping (using a needle to withdraw fluid from the knee). Our
biomechanical explanation presented above and shown in Figure
7e.4 supports the findings of Thun et al.
122
In the case of carpet layers performing the carpet-stretching
task (using a knee-kicker), it appears that the bursae located
posterior and anterior to the patella and the infrapatellar bursa
are in direct contact with the quadriceps muscle and the patellar
tendon, respectively. Under such a repetitive movement condi-
tion, the tendon moves repeatedly over the bursae, causing
mechanical irritation that gives rise to inflammation, causing
fluid to be released into the bursae. Fluid in the bursae produces
swelling and tenderness. If the inflammation is intense, the over-
lying skin becomes red and feels hot when touched. Symptoms
typical of inflammation include
95
swelling caused by accumula-
tion of fluid that may require knee tapping, redness and local
rise of skin temperature caused by increased blood flow around
the injured area, tenderness on touching the affected area, and
impaired function. Early signs of superficial tissue damage due to
sustained kneeling or impacting a knee-kicker may be indicated
by skin redness caused by increased blood flow and therefore local
rise of skin temperature. Therefore, one of the medical/physiologic
A
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Figure 7e.2 (A) Schematic of coordinate system for carpet stretching task. (B) Angular acceleration of thigh center of gravity (C.G.). (C) Horizontal
linear acceleration of shank C.G. (D) Joint reaction forces at knee.
parameters of measurement should be skin temperature distri-
bution and the degree of skin redness that could be used as
preclinical indicators of inflammation/bursitis.
In comparison with frictional bursitis, the condition of hemo-
bursa (bleeding into a bursa) may be produced in people whose
activities require them to make repeated contact with a hard
surface or object, such as those experienced by carpet layers.
In the case of carpet layers, sheer impact force on the knee-kicker
may be sufficient to injure the bursae located posterior and
anterior (pre) to the patella. Blood within the bursae causes
chemical irritation, and in severe cases it may clot, causing adhe-
sion of connective tissue and loose bodies. At this stage, chronic
inflammation is likely to set in. The presence of loose bodies
causes a specific cracking and grating sound when the knee is
flexed and extended. Chu et al
32
showed that the presence of
loose bodies can be quantified by noninvasively measuring and
characterizing the acoustic signature using a special purpose
(20 to 20,000 Hz) microphone (attached to a waveform analyzer)
in an auscultation examination of the knee joint. Development
of this kind of methodology is highly recommended for a future
project because this technique may be sensitive enough to iden-
tify the preclinical signs of the existence of loose bodies as well
as some degenerative knee joint disorders.
In addition to the trauma to the bursae, Thun et al
122
also
reported the existence of arthritic conditions in the carpet layers.
They did not specifically distinguish between osteoarthritis and
Chapter 7e Magnitude of the problem 313
Sustained static loading A Sustained static loading
Repetitive dynamic loading
B
D Sustained static loading C
Figure 7e.3 (A-D) Lower extremity locations of potential pressure points and/or vigorous impact force on body postures of the carpet installation
process.
R
k
R
R
pf
Figure 7e.4 Force configuration in the sagittal plane during impact
phase of the knee kicking cycle. Ground reaction forces are assumed
to be negligible. R
K
, Impact knee force on the knee-kicker;
R
pf
, patellofemoral force; R, resultant force.
rheumatoid arthritis. In the carpet layers case, biomechanics can
be used to explain the existence of potential osteoarthritis.
Previous investigators
77,100
implied and showed that with increase
of articular stresses and asymmetric loads beyond the capacity of
resistance of bone and cartilage tissues, osteoarthritic lesions
appear and develop. From our field study and biomechanical
analysis of the impact data and the position of the knee during
the impact phase of the kicking cycle, we see that the result of
R
k
(impact knee force on knee-kicker) and R
pf
(patellofemoral
force) (Fig. 7e.4) either (1) acts eccentrically at the articulating
surface, creating uneven pressure distribution on the cartilage
and therefore present conditions for developing osteoarthritis,
or (2) acts laterally, resulting in eccentric squeezing of the patella
against the femur that increases localized stress with bone osteo-
phytes, destruction of cartilage, and narrowing of joint space.
Either of the above two conditions in conjunction with the
impacting nature of the load experienced by the carpet layers
give sufficient biomechanical reasons to promote osteoarthritis
of the knee. Whatever the nature of the underlying cause, it
appears that there is a need to quantify the existence of knee
osteoarthritis in carpet layers at a preclinical stage. To date, this
type of degenerative disease (generally irreversible) can be
identified only when the actual sclerotic lesions have appeared
on the tibiofemoral joint surface. These lesions are visible on an
x-ray film.
In our laboratory we have further developed, refined, and vali-
dated a previously reported
133
noninvasive method for quantifying
preclinical biomechanical parameters of knee osteoarthritis.
2,50,111
Briefly, this technique allows noninvasive quantification of
stiffening (or damping) properties of subchondral bone in the
osteoarthritic patients compared with normal subjects. Previous
study
101
has shown that stiffening of subchondral bone may be
used as a preclinical indicator of knee osteoarthritis. The experi-
mental protocol involves attaching single-axis accelerometers
at the tibial tuberosity and femoral condyles of each subject
for collecting heel-strikeinduced acceleration waveforms. The
rationale is that the stiffer subchondral bone of osteoarthritic
patients produces high-frequency bone vibration compared
with those produced by normal subjects. Because of decreased
damping capacity of the subchondral bone, harmful forces
due to external loads (either produced by the occupational task
and/or natural heel strike events) damage the knee cartilage and
eventually traumatize the tibiofemoral bony surfaces. Ultimately,
the incoming forces continue to progress toward the hip, causing
it to become the next target of trauma.
The results from our previous and ongoing studies with
clinically diagnosed osteoarthritic patients
2,52,113
(Bhattacharya,
Watts, and Waters, 2004, unpublished data) indicate that this
technique can differentiate osteoarthritic acceleration patterns
from those obtained from normal subjects. The purpose of this
study
52
was to describe the accelerometric technique used to
estimate tibial damping properties among osteoarthritic subjects.
Tibial tuberosity bone vibration was captured in 8 osteoarthritic
patients and 10 normal subjects with a skin-mounted low-mass
accelerometer described in the literature.
7,25,130-132
The subject was
asked to walk on a force plate.
Trabecular damping was estimated assuming a single degree
of freedom model in which the tibia and foot were considered
together as a lumped mass and the trabecular behaves as a linear
spring and viscous damper.
10,34
During a force plate event
(patient steps across force plate), the single degree of freedom
system responds to the transient force in accordance with the
solution to the second-order differential equation. Using a
frequency response function (transfer function between the
force plate and the acceleration at the tibia), the solution to a
differential equation, a trabecular-damping fraction (ratio, ),
was obtained directly from a measured frequency response func-
tion using a technique adapted from Coleman
34
and Bendat and
Piersol.
10
The results showed that the osteoarthritic subjects have
higher resonant frequency and decreased damping (Fig. 7e.5)
than the normal subjects. It implies that the subjects with
osteoarthritis have a decreased shock-absorbing capacity in the
tibia and stiffer bone compared with normal subjects. Therefore
it is a worthwhile effort to investigate this technique for iden-
tifying preclinical signs of osteoarthritis in the carpet layers.
Based on the above discussion and our previous studies, the
following parameters should be measured as descriptors of
mechanical loading of the knee joint in carpet layers: kneeling
time, knee-kicking frequency, kneeling pressure/force, and knee-
kicking impact force. The above parameters can be used to
define new indices of biomechanical loading of the knee joint
for carpet layers. One such index, called the Cumulative Impact
Loading Index, is described in our earlier publication.
18
The
corresponding clinical/physiologic response variables should
include (1) location and size of inflammation region, (2) skin
temperature distribution of the inflamed region, (3) degree of
skin redness, (4) range of motion of knee joint, (5) acoustic iden-
tification of the existence of loose bodies, and (6) noninvasive
preclinical quantification of an osteoarthritic condition.
Work-related lower extremity
vascular problems
Many occupations require long periods of standing, including
workers in the manufacturing, service, and retail sectors.
Epidemiologic studies have shown certain health outcomes to
be associated with occupational prolonged standing, including
Figure 7e.5 Tibial damping calculated by accelerometric technique.
(From Huang S, Bhattacharya A: Chin J Med Biol Eng 13:255-264,
1993.)
chronic venous insufficiency,
41,57,58,125
varicose veins,
1,56,114,126
low
back pain,
73,85,105
symptom-free venous reflux,
61
hip osteoarthritis,
37
leg and foot pain,
105
varicose symptoms without varicose veins
(hypotonic phlebopathy),
5
venous disease,
42
arthrosclerotic pro-
gression (as measured by ultrasound of carotid intima media
thickness),
56
and trunk varices.
116
Abramson et al
1
estimated the
prevalence of varicose veins in the general population to be
10% in men and 29% in women. Krijnen et al
57,58
found the
prevalence of venous insufficiency in a population exposed to
occupational standing to be 29%. Chronic venous insufficiency
is often unrecognized in the occupational population because
it is sometimes asymptomatic.
58
Much more research is needed
to investigate causes of venous insufficiency.
41
Biomechanical studies have shown prolonged standing to
be associated with increased plantar pressures
81
and pain and
increased leg internal fluid volume.
57,58
Prolonged standing can
cause lower leg and back discomfort.
102
Magora
75
reported a high
incidence of lower back pain for workers standing more than
4 hours a day. In addition to lower back pain, supermarket
workers such as checkout personnel have a high incidence of
lower limb discomfort and pain.
105
Leg discomfort and fatigue is
also found in assembly and quality control inspection workers.
103
Eighty-four percent of French female health care workers stand
more than 4 hours a day, compared with 43% in the general
population.
39
German laundry workers stand 70-80% of their
work time per day.
39
Physiology/biomechanics of prolonged standing
The upright posture poses a challenge for the human cardiovas-
cular system. In the upright position about 70% of the total
blood volume is below the heart level and three fourths of the
blood volume is located in the compliant veins.
104
With upright
posture, the increased hydrostatic pressure causes marked dis-
tension of the veins, causing pooling of the blood as increased
filtration of fluid from the capillaries remain in the interstitial
space (extracellular fluid) of the legs instead of returning to the
heart. In the upright position, the mean capillary pressure of
a person of average height may increase by 80 mm Hg to a value
of about 125 mm Hg.
During sudden upright position, the hydrostatic column of
the blood in the vein between foot level and the heart level is
broken up by a series of one-way venous valves. However, as the
standing time progresses, the blood continues to flow from the
arteries into the lower extremity veins, causing the blood to pool
and thereby forcing the valves to open, causing an uninterrupted
hydrostatic column of blood to form between the foot vein and
the right atrium. Under these conditions, about 600 ml of blood
usually shifts from the central circulation to the veins in the
lower legs.
72
Up to 30 minutes of standing causes the following
responses to take place. When humans stand upright, both cen-
tral venous and arterial pulse pressures fall, causing an increase
in venous muscle tone via innervation of the sympathetic vaso-
constrictor nerves supplying the smooth muscles of the venous
walls. The increase in venous muscle tone increases the stiffness
of the vein walls, causing the pressure of the blood within the
veins to rise; this increased venous pressure then drives the blood
out of the vein toward the right heart.
114
Once the standing task
continues beyond 30 minutes, both the neural and humoral
responses play significant roles. With prolonged standing, the
stimuli to initiate neural/humoral responses are a decrease in
central venous pressure, arterial pulse pressure, and arterial mean
pressure. The neural/humoral responses are an increase in sympa-
thetic activity, plasma norepinephrine, heart rate, vasoconstric-
tion, and vasopressin or antidiuretic hormones.
104
The release of
antidiuretic hormones is modulated by the atrial mechanorecep-
tors that sense the shift in fluid volume to the lower leg as a
decrease in fullness of the vascular system. This hormone has water
and salt retention properties that may constitute an effective
long-term adjustment to the upright posture.
The mechanism behind muscle pain/discomfort due to
prolonged standing is not well understood.
52,113-115
Some human
studies
113-115
using thermodilution techniques (along with hema-
tocrit, hemoglobin, lactic acid, and muscle biopsy) have shown
that submaximal static muscle contraction (such as prolonged
standing) causes an increase in muscle water content due to an
increase in extracellular water (possibly affecting muscle mem-
brane potential due to changes in potassium and sodium con-
tents of the muscle as per Sjogaard et al
113
), and with maximal
static contraction intracellular water increases. One reason for
an increase in water in the muscle is because lactate formed
during fatigue is transported into the t-tubules where it attracts
water and causes t-tubule swelling and vacuolation.
62
Bakke et al
9
in a study on humans showed significant correlation between
muscle edema (as measured by an increase in extracellular fluid
retention by the muscle) and subjective pain/discomfort.
Therefore, previous studies,
28
in which external leg volume was
measured before and after prolonged standing, showed no statis-
tically significant correlations between leg discomfort and leg
volume change. This insignificant relationship could be due to
the fact that an increase in leg discomfort may not be linearly
related to venous pooling, because with sustained standing, com-
pensatory mechanisms may actually reduce the venous pooling
temporarily.
9,104
WORKPLACE ADAPTATION/
RECOMMENDATIONS
Injury/disease prevention plan for jobs
requiring use of knee: carpet layers tasks
The development of an effective injury prevention program
involves three phases: (1) identification and estimation of the
level of the health hazard/injury for a specific job, (2) develop-
ment of a hazard/injury monitoring program, and (3) control
of the hazard. As far as the carpet layers study is concerned,
the hazard has been identified and its potential risk determined.
We, in our laboratory, and others developed techniques to
estimate the level of biomechanical loading and estimation/
measurement of medical/physiologic variables of lower extrem-
ity trauma. For example, to monitor and quantify the level of
external loading exposure to the knee joints during daily carpet
installation activities, we designed and developed an electronic
kneeling meter that can measure and record the number of
kneelings, length of kneeling time, and number of kicks applied
by a worker during a working day
15,20,46
(Fig. 7e.6). These parame-
ters are then used for calculating a cumulative loading parameter
for the knee joint. This unit is a self-sustaining microcomputer
Chapter 7e Workplace adaptation/recommendations 315
system controlled by a microprocessor through a software pro-
gram stored in a nonvolatile microprocessor chip. This device
is worn as a knee pad on the infrapatellar and suprapatellar
regions. The entire system is designed for portability, and the
display and storage of kneeling parameters remains intact for
at least 4 hours before the data need to be downloaded (on a
laptop computer) and stored for future analysis. The use of this
device allows quantification and characterization of the dose of
external loading on knee joints associated with tasks requiring
the use of the lower extremities.
For the quantification and characterization of early medical/
physiologic effects of exposure to chronic low-level biomechani-
cal loading of the knee, a microprocessor-based liquid crystal
thermography technique was developed in our laboratory.
46
The
developed system, which is inexpensive and portable for field
use, uses flexible sheets embedded with liquid crystals that
have both thermal and fluid properties. These sheets are factory
calibrated to produce different colors for known temperature
ranges. The flexible liquid crystal sheets are cut to fit the surface
of the suprapatellar and prepatellar regions of the knee joints.
For the evaluation of the temperature profile of the knee regions
exposed to knee-kicker impact and kneeling tasks, the subject is
first seated in an air-conditioned room with his or her leg inside
a glare-free box. Once the liquid crystal patch is placed on the
knee joint (either suprapatellar region or the prepatellar region),
the colors are allowed to change and finally stabilize. An indi-
vidual thermographic sheet displays its full range of colors
from brown (coldest) to blue (hottest) within a range of 3 or 4C.
These color changes are continuously recorded on tape with a
video camera. The video data are analyzed off-line with the help
of a TARGA-16 based video-digitization system with custom-
developed software that allows calculation of liquid crystal areas
of equal temperature zones. The output of this software allows
us to identify the hot spot regions of the knee joint of the
subject. This technique has been evaluated on arthritic and
rheumatic patients, and the results suggest that the technique is
accurate in detecting joint inflammation in the absence of
visible impairment.
This thermography system was tested at the site of a local
hotel undergoing renovation.
46
Two carpet-installer tradesmen
volunteered to undergo a day of testing with the thermography
sheets. Both were experienced workers with 10 and 11 years
experience as carpet installers, respectively. Measurements were
taken before work began, at mid-morning and mid-afternoon
breaks, just before lunch, and at the end of the work day. Because
the thermography sheets we used had a narrow temperature
range and we did not know what temperatures to expect from
the workers knees, we assembled a collection of thermography
sheets that could detect temperatures from 22 to 42C. The two
tradesmen went about their typical work activities that included
a mix of unloading rolls of carpet from the delivery truck, cut-
ting carpet and pads to size, laying tack strip and molding, and
stretching carpet. We assumed that the workers were spending
about 75% of the work time on their knees as indicated by our
previous study.
18
The individual and combined results for the
upper knee (suprapatellar) of the two workers over the course of
the work day are presented in Figure 7e.7.
Measurements were taken on both the prepatellar and supra-
patellar regions of the knee, but only the suprapatellar are
presented because this part of the knee, which makes contact
with the knee-kicker, produced the most dramatic results. The
highest knee temperature detected was 30.1C. The percentage
of total patch area for each temperature color was calculated by
outlining each color with the computer mouse and using the
customized computer program to calculate the total area for
each color outlined.
The results of this case study indicate that the use of contact
thermography, in conjunction with the analytical methods
described above, may be an effective and expedient means of
obtaining quantitative measures of knee temperature patterns
in response to work involving the knee. Although the increase
in the size of the hot spots on the knees of the two volunteer
carpet installers was steady and consistent over the course of
the day, the exact cause of the inflammatory response cannot be
ascertained from an analysis of thermographic records alone.
Questions to be answered are whether or not the observed
inflammatory response was due to the work that was performed
that day or to an existing knee inflammation that the workers
may have developed over the course of their careers. Other
questions that are raised include whether or not recovery to the
knees would occur overnight, and whether these workers would
demonstrate similar patterns of knee temperature increases while
performing other knee-intensive activities such as walking, stair
climbing, or crouching with a bended knee. A larger more in-depth
study is needed to address these issues. Nonetheless, we conclude
the following from this study:
1. Knee temperatures appear to increase consistently as cumula-
tive biomechanical loading increases.
2. Contact thermography is able to detect these changes.
3. The thermographic system we developed provides a feasible
means of measuring knee temperature at the work site.
Some of the techniques such as those described above are
tested and validated, and others may require some refinement.
What remains to be done is the development and validation of a
RCX
7
Figure 7e.6 Kneeling/knee-impact meter.
100
90
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WORKER 1
A
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WORKER 2
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BOTH WORKERS COMBINED
C
Figure 7e.7 Histograms showing the distribution of thermography patch colors for each worker separately and combined results for both workers.
(From Habes D, Bhattacharya A, Millliron M: Appl Ergonom 24:111-115, 1994.)
dose-response curve in a long-term prospective study that would
be appropriate for development of a trauma/injury monitoring
program. The methods and device(s) described here set the frame-
work within which a long-term prospective study can be devel-
oped in the future. It is through such prospective study that one
can determine the dose-response characteristics of job-related
lower extremity cumulative trauma caused by external loading.
The biologic system is capable of tolerating short-term low
levels of external loading with complete recovery. However, it is
possible, after a certain amount of biomechanical insult to the
knee region, that the biologic system will show early (preclinical)
signs of tissue damage/trauma as manifested by the inflam-
matory process. Even before the inflammatory process sets in
permanently, the workers may show an increasing level of dis-
comfort of the knee joint region as the biomechanical loading
increases due to daily exposure to kneeling and knee-kicking.
In summary, it appears that the dose-response curve may have
several dimensions, including cross-correlation among variables
of biomechanical loading, knee joint discomfort rating, medical/
physiologic response, and incidence of permanent knee injury.
Such a dose-response curve (once established with a large popu-
lation) could be made available to the worker or trade groups,
such as unions, to show its application regarding identifying
their members state of risk by measuring certain cumulative
biomechanical parameter(s) on a regular basis along with proper
and periodic medical evaluation. The primary objective would
be to avoid getting close to the irreversible trauma zone of the
proposed dose-response curve shown in Figure 7e.8. This could
be possible by suggesting proper work practice procedures and
work rotation (rotating workers from knee-kicking activity, which
is more traumatic, to other tasks of the carpet installation job).
We drafted a preliminary guideline for the development of
a work practice guide.
16
It is envisioned that with the avail-
ability of such a monitoring program, one can make significant
improvement in arresting and minimizing the high morbidity
ratio found among carpet layers. Some of the information that
will be generated for carpet layers can be modified for use by
other professions (tile setters, floor layers, etc.), and in other
occupations where the kneeling posture is also common.
In addition to the above-mentioned significance to worker
health associated with the proposed development of a dose-
response curve, tool redesign is certainly another approach that
needs to be explored to investigate methods to further reduce
injury among carpet layers. A study conducted by Liu et al
68
in
which the knee-kicker pad was modeled as a viscoelastic solid,
concluded that the typical pad does little to attenuate the
impulse of the kick stroke. That is, the pad is effective in trans-
mitting the force produced by the workers knee to the carpet
being stretched but does little or nothing to cushion the blow to
the workers knee. The authors concluded that different pad
materials need to be developed that better absorb harmful force
transmissions and distribute the forces more evenly to the knee
and for a longer time. They believed that with future research
such a material could be found that reduces the trauma to the
workers knee while maintaining the sharp impulse applied to
the carpet.
In response to the research described above, NIOSH published
an Alert entitled Preventing Knee Injuries and Disorders in
Carpet Layers.
83
The purpose of a NIOSH Alert is to inform
workers and employers of a health hazard, solicit the public for
assistance in preventing the described health hazard, and provide
recommendations for injury prevention and control based on
what is known at the time. In the Alert, NIOSH recommended
the following:
1. Employers educate workers about the hazards of kneeling and
using a knee-kicker.
2. Workers wear protective knee pads while working on hard
floor surfaces.
3. Power stretchers should be used wherever possible.
4. Conduct research to develop carpet installation methods that
further reduce the physical stress and trauma incurred by
carpet layers.
A power stretcher is a tool that looks like a typical knee-kicker
but is anchored to the opposite wall by attaching a series of
telescoping tubes to its end. Once the power stretcher is spanned
across the width of the room, force is produced by pushing
downward on a handle that uses the leverage obtained from the
stationary wall. Power stretchers are effective and relieve the
worker from impact forces to the knee but are not used as often
as possible because they are expensive, require more setup time,
often lack portability, and cannot be used in small spaces such as
hallways and stairs.
A new type of carpet stretcher mechanism has emerged that
promises to remedy some of the inconveniences of the power
stretcher while maintaining its ability to stretch carpet. Called
the stretcher adapter, it is a short piece of tube attached to
Reversible
trauma zone
Transition
zone
Irreversible
trauma zone
Increase in cumulative biomechanical loading**
I
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e
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i
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y

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f

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a
z
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i
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*
Hypothetical relationship
* Skin temperature distribution pattern captured by thermography
** Cumulative impact loading index, kneeling time, skin pressure
distribution by kneeling meter
Figure 7e.8 Schematic of hypothetical association between
cumulative biomechanical loading of the knee and the early symptoms
of clinical/physiologic outcomes.
the end of the power stretcher head that receives its leverage by
insertion of a sharp pin directly into the floor. The stretcher
adapter puts a hole in the carpet, underlying pad, and floor
and cannot be used when installing carpet over concrete, but it
reduces the setup time for the power stretcher, is lightweight and
inexpensive, and can be used in small spaces such as hallways
and closets (http://mctltd.com/StretchAdapter.htm).
The stretcher adapter also causes no structural damage as
can occur when a power stretcher is anchored against a wall in
the room being carpeted. Innovations like these are what is
needed (provided such devices are properly evaluated and found
satisfactory) to relieve the carpet installer from the hazardous
insults to the knee that have long been associated with this
industry.
Communication with trainers and safety specialists at carpen-
try and floor laying unions indicate that there is more emphasis
on safety and safe work practices now than ever before. Workers
also have better personal protective equipment such as knee
pads that protect the knee and lower leg (www.proknee.com),
cushioned insoles for work shoes, and even cushioned antifa-
tigue material that can be wrapped around any type of shoe
(http://www.safetyseven.com/ergoflash.html). For carpet and
floor installers there are improved tools that reduce fatigue and
physical trauma to the lower extremity such as automatic scrap-
ers for ripping up existing flooring, carpet stretchers that can be
activated with a lever instead of the knee (www.kneeless.com),
and double-headed minicarpet stretchers that more easily and
quickly align seams for carpet that is glued to the floor. Nail guns
used by carpenters eliminate the fatigue of hammering and allow
framing and trim work to be accomplished quickly and effi-
ciently, which means less time spent in hazardous postures such
as kneeling and squatting. The experts say that a worker who is
not fatigued will more likely take the time to work smartly and
safely.
According to one source, the traditional carpet stretcher is
still used, but sparingly. One of the main recommendations of
the NIOSH carpet layer Alert
83
was to more extensively use the
power stretcher. At first this device was not commonly used by
carpet installers because it was cumbersome to use, expensive,
and time consuming to set up. Modern designs are lightweight
and easy to set up, and attachments exist that eliminate the need
to span the stretcher between opposite walls to stretch carpet
(http://mctltd.com/StretchAdapter.htm). These improvements
have made the power stretcher the tool of choice in most carpet
installation jobs.
It is widely believed that comparatively few injuries to the
lower extremity for carpenters and floor layers may be due to
under-reporting. Despite improvements in tools and installation
methods, workers still place a priority on finishing jobs on
time. Sometimes cutting corners and overworking their bodies is
needed to achieve these goals. The bottom line is that more
emphasis on safety and the availability of more safety and health
information, such as the NIOSH carpet layer Alert, may have
made a difference in the musculoskeletal health of building trade
workers, but working smart and safe is a constant struggle that
must continually be reinforced. Ultimately, surveys of workers
in controlled studies must be conducted to determine the true
extent of any changes in the hazards of this type of work and the
manner in which workers cope with it.
Antifatigue mats for jobs requiring
prolonged standing
To reduce body discomfort and fatigue, antifatigue mats have
been used in many industries. Many researchers have investi-
gated the relationships between subjective measures, such as self-
reported body discomfort, while working on different surfaces
(such as an antifatigue mat) and objective measures, such as elec-
tromyography recording on the lower legs and back,
35,40,47,48,74,79,140
leg volume,
28
movements of the ankle and center of pressure,
and other biomechanical parameters.
28,40,47,48,74
Because of the pull
of gravity, prolonged standing may cause poor venous pump
activity, which may cause leg edema and body discomfort.
137
In addition, poor venous pump activity has been documented
as a result of prolonged standing on poor resilient surfaces.
23
The effects of various standing surfaces on venous pump activ-
ity were evaluated in some studies.
21-23,102,103
The results have
shown that antifatigue mats with increased elasticity/stiffness
can increase venous pump activity of the legs and reduce body
discomfort.
28
However, the range of values of elasticity/stiffness
and energy absorption of the floor mats, which are shown to be
beneficial, have not been reported in the literature.
Impact of contaminants on antifatigue
properties of floor mats
In many working environments, such as automobile parts manu-
facturing plants or food processing facilities, antislip and/or
antifatigue mats are often contaminated with water, oil, or other
fluids. The effectiveness of the antislip properties of antislip
and/or antifatigue mats with different contaminations and the
reduction of body discomfort while performing a job task are
not well documented in the literature. The effectiveness of the
antislip property of mats is qualified by manufacturers as
good slip resistance. This measure is not adequate for working
environments because the slip resistance of the mat is related to
the shoe worn by the worker and the task being performed.
29-31
Furthermore, the presence of contaminants such as water and oil
can modify an antifatigue mats mechanical properties, which
have been reported to relieve postural fatigue due to prolonged
standing.
28
Cham and Redfern
28
reported that floor mats with
increased elasticity, decreased energy absorption, and increased
stiffness are associated with lower levels of fatigue of the lower
leg and the back area. However, repeated exposure to oil and/or
water decreases the mats stiffness and elasticity, thereby com-
promising its antifatigue properties. Contaminants also reduce
the antislip properties. Previous studies from our laboratory
showed that postural stability is significantly compromised
during dynamic and semidynamic task performance on slippery
surfaces.
27,28,30,31,71,135
Limited studies
109
from our laboratory also showed that
leg muscle workload associated with bicycling significantly
(p < 0.007) impairs postural stability. Previous electromyographic
studies
51,80
have shown that pedaling activity uses predominately
the same muscle groups (hamstrings, triceps surae, gluteus
maximus, tibialis anterior, and quadriceps) that are needed to
perform standing and walking activities. Seliga et al
109
showed
that postural sway length significantly increased with increasing
workload from 40 to 125 watts, implying postural instability.
Therefore, when postural muscles are overworked for maintaining
upright balance on a slippery surface, it is reasonable to assume
that with prolonged standing/walking on slippery surfaces, the
postural muscles experience further fatigue and discomfort, caus-
ing potential postural instability and fall/near fall-related injuries.
In a pilot study at an auto manufacturing plant, the effect of
task performance on slippery surfaces (concrete and floor mats)
on body part pain/discomfort and slips and their association with
surface coefficient of friction was carried out by our research
group.
70
The results suggest that workers body pain or discom-
fort may be caused by the task characteristics or the combination
of working on the slippery surface and the task characteristics.
Under these circumstances, there is a need to modify the mats
properties in such a way that it has a reduced rate of absorption of
a contaminant such as cutting fluid/oil/coolant and an increased
coefficient of friction value, while preserving the desired material
properties associated with its antifatigue features. One such tech-
nique is to deposit plasma polymerized films onto the mats
to vary the coefficient of friction and to control the uptake of
cutting fluid/coolant/oil.
118-121
The above literature review raises several questions regarding
the floor mats used in industries where workers have to perform
tasks during prolonged standing on mats contaminated with oil/
coolant/cutting fluid: How do contaminants modify the mechan-
ical properties of the floor mats? Do contaminants detrimentally
modify the antifatigue properties of the mats? Do antislip
mats provide proper frictional properties as well as antifatigue
properties?
Shoe inserts/insoles for jobs requiring
prolonged walking
Because walking and running give rise to heel strikeinduced
forces in the musculoskeletal system, the transmission, absorp-
tion, and attenuation of energy that intakes to the skeleton due
to heel strike are an important component of bone physiology
and pathology.
44,84,98,134
The human locomotion system, which
consists of natural shock absorbers (joints with viscoelastic
components, articular cartilage, meniscus, intervertebral disks,
trabecular bone, etc.), is subjected to constant insult not only
during weight-lifting activities but also during normal daily
activities such as walking and running.
6,16,130,131
During heel
strike, the vertical force component acting on the foot is on the
order of 1.5 times the body weight depending on walking veloc-
ity.
16,129
These force waves are gradually attenuated by the bodys
natural shock absorbers on their way toward the head. The
process of force wave attenuation is the bodys natural way of
protecting the vital organ, the brain. In healthy subjects, 70%
of the incoming shock waves are absorbed by the bodys natural
shock absorbers before it reaches the forehead.
7,16,44,130,133,134
Among all natural shock absorbers in the human body, the
trabecular bone has the highest capacity (170 times higher than
that provided by the cartilage) to attenuate incoming shock wave
associated with heel strike during walking and running.
96
Previous
researchers have shown that such cumulative loading may give
rise to gradual fracture of subchondral bone trabeculae, which
through healing of the fracture actually renders the subchondral
bone stiffer, thereby decreasing its shock-absorbing capacity.
94,97,99,124
Such stiffening of subchondral bone has been found to be
associated with osteoarthritis, one type of degenerative musculo-
skeletal disease.
45,94,97
Based on the above discussion of the potential detrimental
impact of heel strikeinduced trauma of the knee joint, it is
reasonable to use a shock-absorbing type of material in the lower
extremities to dampen the incoming shock waves. The use of
shoe inserts and insoles have been reported in the literature
to help minimize pain and discomfort associated with degenera-
tive disorders of the knee such as osteoarthritis. In our laboratory,
a study
110
with 24 subjects (normal and osteoarthritic patients)
was carried out to determine the impact of shoe insert (pad) in
reducing heel strikeinduced acceleration measured at the tibial
tuberosity. The results showed that a shoe insert or pad reduced
the high-frequency heel strike force-induced shock waves over a
larger frequency range as compared with that provided by the
physiologic shock absorbers available in the human body when
a shoe insert was not used.
Specialized shoe orthotics have been evaluated to determine
their effectiveness in minimizing osteoarthritis associated
pain/discomfort.
84
Kerrigan et al
53
tested lateral-wedged (5 degrees)
insoles and found them to be biomechanically effective in poten-
tially reducing loading of the medial compartment in patients
with knee osteoarthritis. In a study by Toda et al,
123
two types of
shoe inserts were evaluated. The effectiveness of a novel lateral
wedge insole with elastic strapping was compared with that
of a traditional shoe insert/insole in 90 female subjects with
osteoarthritis of the knee in an 8-week study. The subjects
wearing the novel lateral wedge insole with elastic strapping
showed a significant improvement in their pain and decreased
femorotibial angle and talar tilt (i.e., leading to valgus angulation
of the talus). For the traditional patients wearing shoe inserts
such improvements were not found. Although Kerrigan et al,
53
Toda et al,
123
and others
36
reported some beneficial effects of
the use of laterally wedged insoles, Maillefert et al
76
did not
show any pain relief from short-term (6 months) use of the shoe
insert in medial femorotibial osteoarthritic patients. In addition
to the use of shoe inserts, there is some evidence in the literature
regarding the role of exercise programs for minimizing insult
to the knee joint. Oddis
84
recommended use of isometric mus-
cle strengthening of the quadriceps, which may act as the shock
absorber for the injured knee.
Although studies of shoe inserts in osteoarthritic patients
have been well documented in the literature, there are a lack of
data regarding the use of this form of intervention in occupa-
tional populations. Finally, there is a need for research studies
where shoe inserts and specialized exercise programs can be
tested as preventive tools in workers exposed to activities requiring
prolonged walking and standing.
A two-part case study from an industry in
workplace accommodations for an acute
knee injury and subsequent chronic pain,
discomfort, and work restrictions
Case study part 1: Prevention of recurrence
of a knee injury that resulted from a fall while
descending a staircase and carrying a 24-pound
power tool
The worker and task
A right-handed 52-year-old man approximately five feet ten
inches tall and weighing about 210 pounds worked as a main-
tenance and service technician for over 18 years for the same
company. At the time of this writing, he was one of seven tech-
nicians performing roughly the same tasks. His job required
frequent walking throughout the facility and occasionally
ascending and descending staircases while carrying various tools
and equipment that weighed from just a few pounds to nearly
40 pounds. He estimated that he typically climbed and descended
staircases three to five times during each regular 8- to 10-hour
shift. The nature of the business and potential safety hazards
required him to wear steel-toed boots with metatarsal arch pro-
tection, a flame-resistant long-sleeved jacket, a hardhat, eye
protection, and hearing protection.
The facility where he worked was built in the early 1970s,
and it had not changed significantly over the next 30 years,
except for occasional cleaning, repairs, and minor alterations to
the walking and working surfaces. Until the spring of 2001, this
worker had no history of knee or lower extremity injuries or
discomfort and could not recall experiencing any significant
slips, trips, or falls during his 18 years of service. He reported to
be very familiar with the facility and until the experience
described below had not missed a day of work as a result of a
work-related mishap. However, according to the companys
Occupational Safety and Health Administration (OSHA) 200 logs,
there had been three other lost-time injuries to three separate
workers resulting from slips, trips, and falls during the previous
3 years.
The accident and injury
One afternoon in April 2001, the worker was returning to the
tool crib after completing a job that required the use of a
powered chipping hammer to break concrete. He reported carry-
ing the tool, which weighed about 24 pounds, in his right hand
and walking at a moderate pace. He decided to cross over
a bridge that recently had been closed for repairs but had been
reopened. He stated that he typically had crossed the bridge
many times in the past but that his regular path over the
bridge had been altered for about 3 days while repairs to the
bridge were in progress. The bridge was constructed with seven
metal steps up one side, a platform over and across some
mechanical equipment below, and seven metal steps down the
other side. The worker climbed up the first set of steps, crossed
the platform, and while descending the other side, misjudged a
step, lost his balance at about the third step from the bottom and
fell to the floor, dropping the power tool and feeling a sharp
burning pain in his right knee. After the fall, he stood up
carefully and took a few steps toward the chipping hammer that
had slid several feet across the floor, but he could not bear
the pain so he sat down on one of the steps and then called and
waited for assistance. An emergency medical examination that
evening discovered a torn medial collateral ligament in his
right knee that would require surgical repair and 3 to 4 weeks of
lost work.
Safety and ergonomic assessment
Recall that the worker had no history of knee or lower extremity
disorders and did not recall experiencing any significant slips,
trips, or falls during his 18 years with the company. Also, he had
become very familiar with the facility and until this accident
had not missed work as a result of an on-the-job mishap. Therefore,
the assessment of the safety hazards and ergonomic risk factors
began with the design and construction of the staircase at the spe-
cific location of the accident according to the following criteria:
1. Standard conventional angle of stairway rise (slope), height
of each step (riser), depth of each step (tread run), slip resist-
ance of each tread and leading edge (nosing), and uniformity
throughout the entire flight of stairs per:
a. OSHA 29 CFR 1910.24 (e): Angle of stairway rise
88
b. OSHA 29 CFR 1910.24 (f): Stair treads
89
c. Lehmann
65
: Stairs of the following dimensions require the
least energy consumption and seem to cause the fewest
accidents.
59
i. Slope of 25-30 degrees
ii. Recommended formula: 2h + d = 630 mm (24.8 in);
where h = height of riser and d = depth of tread
d. Rapid Entire Body Assessment, REBA
49
Assessment results
OSHA 29 CFR 1910.24 (e)
88
states that fixed stairs shall be
installed at angles to the horizontal (slope) of between 30 and
50 degrees. The 43-degree slope of the staircase at the location
of the accident was in compliance with the standard.
Table 7e.1 from the OSHA standard
88
shows riser and tread
run combinations that when uniform throughout the entire
flight of stairs, produce a stairway within the permissible range.
The table also shows the slope (angle to horizontal) produced
by each combination and that each step of a stairway having a
43-degree slope should have a riser of approximately 8-1/2
inches and a tread run of roughly 9 inches. OSHA 29 CFR
1910.24 (f) reemphasizes that the risers and tread runs shall
be uniform throughout any flight of stairs.
89
Each of the seven steps that were being descended by the
worker at the time of the accident were measured as shown in
Table 7e.1 (accuracy 1/8 inch) and numbered from the top step
to the bottom. The measurements show that the bottom three
steps had rise dimensions that did not comply with Table 7e.1 of
the OSHA standard,
88
and that the riser dimensions were not
Table 7e.1 Stairway riser and tread run in case
study part 1
Step no. Riser (in inches) Tread run (in inches)
7 8-5/8 9-0
6 8-1/2 9-0
5 8-1/2 8-7/8
4 8-3/8 9-0
3 8-0 9-0
2 7-7/8 8-7/8
1 9-5/8 9-1/8
uniform throughout the flight of stairs. Further investigation
revealed that steps 2 and 3 had been repaired because they had
become rusted and had partially broken loose from the metal
frame. Steps 2 and 3 had been raised slightly and rewelded to
the frame, which shortened their riser dimensions by 5/8 and
1/2 inch, respectively, consequently increasing the riser of step 1
by 1-1/8 inches.
OSHA 29 CFR 1910.24 (f) states,
89
all treads shall be reason-
ably slip-resistant and the nosings shall be of non-slip finish.
Welded bar grating treads without nosings are acceptable pro-
viding the leading edge can be readily identified by personnel
descending the stairway and provided the tread is serrated or is
of definite non-slip design. The treads of the stairway at the
accident location were welded bar grating without nosings, and
their leading edges were not clearly identifiable. The tread was
serrated and of nonslip design.
According to Lehmann,
65
a staircase slope of 25-30 degrees
with uniform risers of 170 mm (roughly 6-5/8 inches) and tread
runs of 290 mm (roughly 11-3/8 inches) requires the least energy
consumption and seems to cause the fewest accidents. Lehmanns
recommendation for the most efficient riser and tread run
dimensions can be expressed by the formula
2h + d = 630 mm (24.8 in)
where h = height of riser and d = depth of tread.
Steps 4 through 7 of the 43-degree-slope staircase where the
accident occurred had relatively uniform risers (h) of an average
8-1/2 inches and tread runs (d) of roughly 9-0 inches. Although
the 43-degree slope fell within range of the 30-50 degrees spec-
ified by OSHA, it exceeded the most efficient slope recom-
mended by Lehmann
65
by 13 to 18 degrees. Also, substituting
the 8.5 inches for h and 9.0 inches for d in the formula gives
the result 2(8.5) + 9.0 = 26.0 inches, which is 1.2 inches greater
than the ideal.
Other assessment tools
Other ergonomics assessment tools that have been used previ-
ously in the facility to identify risk factors related to the various
types of injuries and discomforts reported by the workers are
the Rapid Upper Limb Assessment (RULA),
78
the Rapid Entire
Body Assessment (REBA),
49
the Job Strain Index (JSI),
82
and the
Washington State Caution/Hazard Zones (WAC 296-62-051).
136
Each of these tools focuses almost exclusively on the upper
extremities, with the possible exception of REBA. Although
REBA does not address stresses to the lower extremities specifi-
cally, it does include the effect of the legs in its postural analysis
of the entire body.
REBA is a postural analysis tool developed especially for
the type of unpredictable working postures found in health care
and other service industries.
49
Because the working postures of
a maintenance and service technician are often unpredictable,
REBA was applied after the accident, in this particular case to
determine the action level (i.e., risk level and action required)
of the task of descending the staircase while carrying a 24-pound
tool. The results of REBA are summarized below:
Score A (trunk, neck, and legs) = 7 (on a scale of 1 to 12)
= 4 + 2 (load/force: > 10 kg for the 24-lb tool) + 1 (load/

force: shock or rapid buildup of force from misjudgment
of step)
Score B (upper arms, lower arms, and wrist) = 1 (on a scale of

1 to 12)
Score C (combination of scores A and B from Table C) = 7 (on

a scale of 1 to 12)
REBA score = 9 (on a scale of 1 to 15)
= 7 (score C) + 1 (activity score: static load of carrying tool)

+ 1 (activity score: action caused rapid large range in pos-
tures or an unstable base)
REBA action level = 3 (on a scale of 0 to 4)
High risk level requiring action necessary soon.

In retrospect, if REBA had been applied beforehand, it would
have identified the task as high risk in need of corrective action
soon, but a question remains: What would have, or should have,
triggered the necessity for an assessment, since simply returning
a tool to the tool crib typically would not be considered a
particularly hazardous task? Answer: The repairs to the bridge
should have prompted a safety inspection and an ergonomics
assessment of the changes made to the walking and working
surfaces over the bridge.
Conclusions and corrective actions
As a result of the accident and injury and following the
assessments according to OSHA 29 CFR 1910.24 (e) and (f),
Lehmanns
65
empirical data, and REBA, the following conclu-
sions were made and corrective actions implemented:
1. The first three steps on the descending staircase of the bridge
were replaced. The new risers were each 8-1/2 inches high and
the tread runs 9 inches deep (accuracy 1/8 inch). A complete
inspection of the entire bridge and staircase was performed,
and an inspection schedule of all bridges and staircases
throughout the facility was developed.
2. The leading edges of all the steps at the bridge were made
clearly identifiable using yellow and black diagonally striped
tape. A plan and schedule to identify unmarked steps and to
apply tape as needed was implemented.
3. The following long-term plans were made (Case Study Part 2
covers the long-term accommodations in greater detail):
a. Reduce the slopes and change the risers and tread runs of
the staircases at the location of the accident and through-
out the facility to match Lehmanns
65
recommendations as
closely as possible.
b. Relocate the tool crib and strategically locate tool storage
cabinets to minimize transit hazards (i.e., climbing and
descending stairs), distances and times.
Case study part 2: Accommodations for chronic
knee pain and work restrictions while walking,
while climbing stairs, and during static standing
subsequent to the knee injury described in case
study part 1
The worker and task
The 52-year-old maintenance and service technician described in
the first part of this case study returned to his regular job in early
June 2001, about 7 weeks after his knee injury. Although modi-
fications had been made to the staircase that contributed to his
injury and to many of the other staircases to bring them into
compliance with OSHA 29 CFR 1910.24 (fixed industrial stairs),
91
the job still required the following physical activities:
Frequent walking on various surfaces;
Ascending and descending staircases three to five times a day

while carrying tools;
Climbing portable and fixed ladders four to five times per

week;
Occasionally climbing on various machines and structures to

perform maintenance and service tasks;
Static standing on a concrete floor for up to an hour at a time;
Occasionally crouching, once or twice a day, to work on low

level equipment.
Also, the safety hazards in the plant had not changed; therefore
it was a requirement to wear full foot protection and all the
personal protective equipment described in Case Study Part 1.
Modifications made and planned during
the workers absence
During the injured workers 7-week absence, the first three steps
on the descending staircase of the bridge at the location of
the accident were replaced with steps of the correct design and
dimensions. Inspections and repairs of the most frequently used
bridges and staircases throughout the facility were completed,
and the leading edges of most of the steps were made clearly
identifiable using yellow and black diagonally striped tape.
In addition to the above modifications, the following long-
term plans were made:
1. To reduce the slopes and change the risers and tread runs of
the staircases at the location of the accident and throughout
the facility to match Lehmanns
65
formula as closely as possible.
2. To relocate the tool crib and strategically locate tool storage
cabinets to minimize transit hazards, such as climbing and
descending stairs while carrying tools and excessive walking
distances and times.
Physical discomforts, limitation,
and work restrictions
Upon returning to his job, the worker felt confident in his ability
to perform the essential functions of the job and was relatively
satisfied with the progress of his recovery. However, he reported
mild to moderate pain and occasional swelling and joint stiffness,
especially after walking for more than about 2 hours, standing for
more than an hour, and especially after climbing stairs of slopes
greater than about 40 degrees, climbing ladders more than twice
daily, or crouching for more than a minute or two.
Postoperative medical reports from the physician of record
stated that the surgery to repair the medial collateral ligament in
the right knee, as well as the subsequent recovery, had progressed
with no complications; however, some preexisting degenerative
joint disease (osteoarthritis) was discovered. The physicians report
placed restrictions on duration and frequency of walking, static
standing, climbing stairs and ladders, and crouching and stressed
the importance of avoiding reinjury from a slip, trip, or fall.
A written opinion and functional capacity evaluation from a
physical therapist stated that the worker had participated cooper-
atively in his rehabilitation program thus far and was progressing
reasonably well; however, it would take approximately 1 year for
him to reach maximum improvement in strength and range of
motion.
In summary, the opinions from the worker himself, the physi-
cian of record, and the physical therapist provided the following
work restrictions for which reasonable accommodations were to
be made during the first 6 to 8 weeks of his return to work (work
restrictions to be reassessed after each 6- to 8-week period):
1. Walking is to be limited to 2 hours per day.
2. Static standing must not exceed 1 hour per day.
3. Staircases with slopes greater than 40 degrees are to be avoided.
4. Climbing portable and fixed ladders is to be restricted to
twice daily.
5. To prevent unexpected or unnatural loading of the knee
(i.e., twisting, lateral stress, hyperextension, extreme flexion,
etc.), the most obvious slip, trip, and fall hazards should be
identified and removed wherever practicable.
6. All crouching, squatting, kneeling, or any activity that
requires the right knee to be flexed more than 90 degrees is to
be avoided.
7. Climbing on structures without regulation steps, grab bars,
walking platforms, and handrails must be avoided.
8. Jumping down from platforms or other structures is to be
prohibited.
Assessment methods and tools
In addition to ensuring compliance to the above restrictions for
the injured worker, the following safety standards and ergonom-
ics guidelines were to be enforced for the purpose of minimizing
risk of injury (or reinjury) to any of the workers:
1. All staircases were to be equipped with railings and guards in
compliance with OSHA 29 CFR 1910.23 (d)(1)(i) through (v).
87
2. The most frequently used staircases were to be modified so
that the tread heights and depths fit as closely as possible the
following formula recommended by Lehmann.
65
According
to Kroemer and Grandjean,
59
stairs of these dimensions are
not only the most efficient but also seem to cause the fewest
accidents.
2h + d = 630 mm (24.8 in), where h
= riser height and d = tread depth
3. All portable ladders were to comply with OSHA 29 CFR
1910.25 (Portable wood ladders),
91
and 1910.26 (Portable metal
ladders),
92
and with 1910.27 (Fixed ladders).
93
4. All walking surfaces were to be inspected and brought into
compliance with OSHA 29 CFR 1910.22 (General requirements)
86
regarding housekeeping and aisles and passageways.
Controls and interventions
Table 7e.2 shows the controls and interventions that were
implemented over a period of approximately 90 days to facilitate
compliance to the prescribed work restrictions, safety standards,
and ergonomic recommendations.
Three-year follow-up
In June 2004, a brief telephone interview of the injured worker was
done to determine his condition and to check the current status
and effectiveness of the workplace modifications. In summary,
the injured worker was still actively employed as a maintenance
and service technician but in a more supervisory role. He esti-
mated that his workload had been reduced approximately 20%
to 30% since the time of his accident and shortly thereafter. His
work restrictions have been lifted, but he still experiences occa-
sional stiffness and discomfort in his right knee; however,
he sincerely believes that the modifications to the bridges,
stairways, and the other walking-working surfaces have made his
job, and the work of all the maintenance and service technicians,
safer and less physically demanding. Since his accident in
April 2001 and following the implementation of the workplace
modifications described above, there have been no lost-time
injuries reported from slips, trips, and falls according to the
OSHA 300 logs. Comparatively, during the 3 years before the
accident described in this case study there had been three other
lost time accidents from slips, trips, and falls.
Table 7e.2 List of controls and interventions to facilitate compliance to work instructions, safety standards
and ergonomic recommendations
Restriction, standard, or guideline Control or intervention
Walking < 2 hours per day An electric-powered cart was purchased for transportation across flat surfaces.
The main tool crib was moved to a central location and three tool cabinets were placed near the three most
frequently visited work areas.
Static standing < 1 hour per day Antifatigue matting was placed on the concrete floors in eight locations.
Five adjustable-height standing support stools were placed where standing work was common.
Avoid staircase slopes > 40 degrees Five bridges with staircases were modified to comply with the formula 2h + d = 630 mm (24.8 in) which
reduced their slopes from approximately 43 to about 35 degrees. All frequently used staircases with slopes
> 40 degrees that couldnt be modified were marked accordingly.
Climbing ladders < twice daily A mobile cherry picker was purchased for the maintenance and service department.
Eliminate slip, trip, and fall hazards, and all A videotape of all walking surfaces throughout the facility was developed and presented to management and all
walking surfaces must comply with maintenance and surfaces technicians. A 1-year corrective action plan with monthly status checks was developed.
29 CFR 1910.22
86
A 2-hour training program in preventing slips, trips, and falls was given to all maintenance and service
technicians.
No crouching, squatting, or kneeling Two large electric motors and one pump were raised from floor level to elbow height. Two standing support
stools were placed at these locations, and four adjustable low stools were placed near four machines
where low-level work is performed regularly.
No climbing on structures without steps, grab Steps with slip-resistant treads, grab bars, and walking platforms were installed (welded) to two machines that
bars, etc.; and no jumping down from are climbed on regularly.
platforms
All staircases must have railings and guards Stairways < 44 inches wide were inspected to comply with:
per 29 CFR 1910.23 (d)(1)(i) through (v)
87
Both sides enclosedhand rail on right side descending
One side openstair railing on open side
Both sides openstair railing on each side
Stairways > 44 inches but < 88 inches wide were checked for compliance with:
Hand rail on each enclosed side
Stair railing on each open side
Stairways 88 inches wide were checked for:
Hand rail on each enclosed side
Stair railing on each open side
Intermediate stair railing midway
Frequently used staircases should comply Although the bridge and staircase at the accident location plus four other bridges in the main walkway of the
with the formula, 2h + d = 630 mm facility had been made OSHA compliant since the accident, they were further modified to comply also with
the Lehmann formula.
For example, the average riser and tread depth of the 43-degree steps at the accident location were changed
from 8-1/2 and 9 inches, respectively, to 7-1/4 and 10-1/4 inches, which reduced the slope to about
35 degrees and required the bridge to be lowered and the staircases to be lengthened.
All ladders must comply with 29 CFR All ladders were inspected and required to be in good condition or otherwise removed from service and
1910.25, 26, and 27
91-93
tagged.
A 2-hour training program in ladder safety, including maintenance and utilization of ladders, was given to
all maintenance and service technicians.
Summary and conclusions
This two-part case study describes workplace modifications
that were applied, in part 1, for the prevention of the recurrence
of an acute injury resulting from a fall while descending a stair-
case and, in part 2, to accommodate the subsequent long-term
pain, discomfort, and work restrictions of the injured worker.
The task that was being performed when the injury occurred was
assessed using the OSHA standard for walking-working surfaces,
namely related to staircase design and construction and an
ergonomic formula that suggests an efficient and safe relationship
between staircase riser, tread depth, and slope. An ergonomic
assessment of the task also was performed using the REBA tool.
Each assessment method discovered noncompliances and risk
factors that were determined to be likely contributors to the
accident. The workplace modifications were directed toward
correcting the noncompliances and eliminating or significantly
reducing the ergonomic risk factors that were identified. A brief
follow-up approximately 3 years after the accident indicated that
the modifications were instrumental in allowing the injured
worker to return to his regular job and to prevent recurrence of
a similar accident and injury.
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C HA P T E R
8
Ankle and Foot
Epidemiology of the
Ankle and Foot
Victor Valderrabano and Beat Hintermann
Acute and chronic injuries of the foot and ankle are among
the most common injuries in the musculoskeletal system. Based
on 15,000 completed questionnaires by family shoe store
customers, it was determined that 40% of the population in the
United States has foot problems, 12% of which have had surgery
and 7% of which have been untreated.
51
It has been reported that
for every 300 men working in heavy industry, 15 working days
per month are lost as a result of foot problems, 65% of which are
the result of trauma.
31
The amount of athletically related injuries
is substantially increasing due to the aging population, the grow-
ing popularity of recreational sports activity in our society,
and the greater numbers of professional active athletes. In sports
practice, however, it is often difficult to distinguish and strictly
separate work-related from recreation-related injuries.
The following general comments on the epidemiologic assess-
ment of disorders and injuries to the foot and ankle are meant
to show the general problems and difficulties of attempting to
reveal and compare data from a literature review. More detailed
considerations about epidemiology are made separately for
work-, military-, and sport-related injuries, although as mentioned
earlier, strict differentiation between these activities is often not
possible. The number of athletically related injuries has grown
coincident with an enlarging search by the public for specialists
to provide the necessary treatment. Hence, it is not surprising
that athletic-related injuries are at this time among the best inves-
tigated. The knowledge gleaned from such specific studies has
contributed to a better understanding of injuries occurring dur-
ing work and military service and has led to improvements in
equipment. Shoe construction and design, for example, have
improved markedly due to the research activities of sport shoe
companies.
METHODOLOGY OF EPIDEMIOLOGIC
STUDIES: CRITICAL ASPECTS
One of the goals of preventive medicine is to reduce the health
risk of both occupational exposure and athletic participation
through recognition and control of the risk factors. From the
vantage point of careful epidemiologic study, it is possible to
identify and quantify risk along with the incidence and preva-
lence of injury for a given set of conditions.
107
To analyze epidemiologic data properly, it is critical for
the population being analyzed to be assiduously defined. Many
studies of athletic injuries that have engendered prejudicial think-
ing about injury causes are flawed because of their methodology.
27
Most of the existing information on observed causes of athletic
C HA P T E R
8a
injuries comes from accounts of case studies, many of which
report an injury rate but often fail to define accurately the
population at risk. For instance, the prevalent idea that runners
who over-pronate are at a greater risk for injury, as reported by
James et al,
67
was fostered by noting that 58 of their 180 patients
had a pronated foot configuration. This study does not take into
consideration the total number of people in the running popu-
lation from whom this select group was derived who also pronate
but have not been injured.
Another liability of epidemiologic studies is their failure
accurately to define the factor to be analyzed. Sport injury studies
show significant variations in the definition of what constitutes
an injury. It is difficult, for example, to compare studies where
an injury is anything that causes an athlete to require medical
attention and lose time from participation
15
with those that have
much stricter definitions and classifications.
62,132,134
The compar-
ison difficulties are increased further when different sports
and participation levels are compared. There may be significant
differences between the injury of a recreational runner and that
of a professional rugby player.
26
In addition, elite and endurance
athletes are characterized by the psychologic iceberg profile,
which includes scores below the population average on mood
states such as tension, depression, anger, fatigue, and confusion
along with above average scores on vigor.
92
During years of hard
training, pain recognition and processing by the central nervous
system may change.
Finally, the homogeneity of the population being studied is
important. This relates to such considerations as exposure to
injury, age and gender differences, preexisting injury, and other
variables that may significantly confound risk.
27
Several studies
have demonstrated, for instance, that weekly running mileage is
the single most critical factor affecting injury risk in the running
population.
85,136
At distances of over 64 km (40 miles) per week,
the injury rate seems to increase exponentially. Through all these
studies, other risk factors have not been confirmed.
WORK-RELATED INJURIES
Epidemiology
Attempts to characterize and quantify work-related injuries to
the foot and ankle are few. Jobs involving extensive manual
material handling or vehicular operations are those most often
listed by employees with foot-related injuries.
Etiology
Work-related foot and ankle injuries have been associated
with falling from ladders;
100
being struck by boxes, metal objects,
or vehicles; being caught in, under, or between vehicles or
machinery;
98
and having cut or laceration injuries.
OSullivan et al
100
showed that ladder fall injuries are associ-
ated with foot fractures, the male gender (89%), a median length
and hospital cost of 1 week and US$3950, respectively, and a
median duration of disability and unemployment of 6 weeks.
From a total of 990 work-related injuries to the foot, being struck
accounted for 58% across occupational groups.
98
Regardless of
the industry group, metal items and vehicles were related to
51% of all work-related foot injuries. Bazroy et al
7
found 15%
of cuts and laceration injuries to the foot and ankle in a glass
bottle manufacturing plant. Significant risk factors were age
(less than 30 years) and experience (less than 2 years). Technical
factors responsible for injury were a hazardous work site in
37 cases (38.5%), inadequate protection with safety wear in
32 cases (33%), and proximity to machines in 14 cases (14.6%).
Human factors identified were lack of protective wear in
43 episodes (45%), overconfidence in 18 episodes (18.7%), and tim-
ing error while working with machines in 11 episodes (11.4%).
Prevention
To reduce the incidence of foot injuries, workers in many indus-
tries are required to wear safety footwear incorporating a steel-
toed cap. In Australia, an investigation of 321 workers employed
in a broad range of work activities and required to wear safety
footwear revealed an extremely high percentage of subjects (91%)
reporting one or more foot problems that were verified by a pro-
fessionally trained podiatrist.
84
Most of these subjects believed
that the safety footwear either caused the problem or adversely
affected an existing foot condition. The main shoe concerns
were excessive heat (65%), inflexible soles (52%), weight (48%),
and pressure from the steel-toed cap (47%). As the priority, safety
may obviously conflict with comfort. Ideally, knowledge would
compromise with experience in choosing shoes for industry
workers to allow the best possible supply of safety footwear.
MILITARY-RELATED INJURIES
Epidemiology
Lower limb injuries, mainly to the foot and ankle, are the most
common injuries in military service. In a survey of 350 male
recruits of the Royal Australian Army Corps, Rudzki
115
reported
an 80% rate of foot and ankle injuries. Among the U.S. Marine
Corps, training-related initial injuries to the foot were found at
a rate of 3.0 new injuries per 1000 recruit-days.
80
The highest
specific rates of injuries occurred with stress fractures to the foot
(0.56 per 1000 recruit-days), ankle sprains (0.53), and Achilles
tendinitis (0.39).
In a prospective study, Bush et al
21
examined the epidemiology
of blisters and their association with subsequent injuries in
2130 male U.S. Marine Corps recruits, who experienced an
incidence of 2.05 blisters per 100 recruit-months. Recruits with
blisters were 50% more likely to experience an additional training-
related injury. In combination with other related injuries, blisters
resulted in 159 clinic visits, 103 days of assigned light duty, and
177 days lost from training.
Among an air assault division, foot and ankle injuries were
the most prevalent and severe category of injury for combat unit
soldiers.
39
In a 1-year period, the average combat unit soldier
sustained 0.16 foot injuries with an estimated 3.2 effective duty
days lost. A prospective study of 295 male Israeli military recruits
reported a 31% incidence of stress fractures,
90
most of which (80%)
were in the tibial or femoral shaft, whereas only 8% occurred in
the tarsus and metatarsus. Excessive rates of stress fractures were
found also by other authors.
13,14,47,114
Etiology
Stress fractures (Fig. 8a.1) are common injuries sustained during
military training. Improper advance physical preparation and
excessive physical demands during military service may cause
most of these injuries to the foot and ankle.
13,14,48,72
Typically,
fatigue fractures have been seen mostly in the first months of
service, indicating an acute overuse injury of bones.
114
In the past, pes planus or flatfeet have been a disqualifying
factor for military service. Specific studies, however, have shown
that those recruits with flat or pronated feet had no greater inci-
dence of stress fracture than the normal population.
49
Rudzki
116
showed that abnormalities of the foot (pes planus, pes cavus,
hallux valgus) were not significant factors in the development
of injury during recruit training. In contrast, another study, this
one involving Israeli military recruits, showed that those with
low arches had a higher incidence of metatarsal stress fractures
than did those with higher ones, whereas the number of stress
fractures of the tibia and femur was lower in low-arch than in
high-arch feet.
121
Heavy loads have been recognized as a risk factor for foot
and ankle injuries during endurance exercises in the military.
Reynolds et al
105
reported that 36% of soldiers were injured dur-
ing a 161-km march over 5 days carrying an average load mass
of 47 kg. In this study smoking and younger age (< 20 years)
were independent risk factors for injuries.
Other causes of military-related foot and ankle injuries are
cold weather injuries
30,88,128
and inflammatory foot lesions.
63
Milgrom et al
88
showed evidence of cold weather being a risk
factor for Achilles paratendinitis. They explained that a fall in
temperature of the Achilles paratendon may increase the viscos-
ity of the lubricant, in turn increasing friction and risk for
Achilles paratendinitis.
Prevention
In general terms, warming up before exercising may be one of
the most important factors in lowering acute foot and ankle
injuries.
88
Meticulous foot care such as skin and nail hygiene
may prevent infections and blisters. Furthermore, higher quality
and ergonomics of shoes, insoles, and equipment may avoid
overload injuries effectively.
To determine the effect of appropriate shoe fit and training
shoe type on the incidence of overuse injuries, the Israeli Defense
Forces Medical Corps conducted a prospective study.
38
Among
infantry recruits, they found that three shoe widths for each shoe
length size were necessary to adequately accommodate the
recruit populations foot anatomy. Recruits compensated for
the lack of available shoe widths by choosing larger shoe sizes,
which did not result in a higher incidence of overuse injuries.
Switching to tennis sport shoes substantially reduced calcaneal
stress fractures in military recruits.
52
A study of South African
Chapter 8a Epidemiology of the ankle and foot 332
military recruits reported a reduction in overuse injuries by
incorporating a shock-absorbing neoprene insole into the shoe
used in training.
119
Surprisingly, however, no mid- to long-term
studies have systematically assessed the effectiveness of footwear
improvements on soldier fitness.
SPORT-RELATED INJURIES
Epidemiology
Injuries to the lower extremities constitute most injuries in most
sports, especially those involving running, jumping, and kicking.
Twenty-five percent of 12,681 injuries in the top 19 most com-
mon sports injuries seen in a multispecialty sports medicine
clinic occurred at the ankle and foot. The percentages of foot and
ankle injuries varied substantially from sport to sport, as did the
proportion of sprains versus overuse injuries at each location.
46
If injury rates for the foot and ankle are determined from studies
performed for various sports (Table 8a.1), the magnitude of
the athletic injury problem can be estimated by multiplying
these rates by the number of participants in the given sport.
Obviously, some sports have an extremely high risk for injuries
to the ankle or foot (Table 8a.1), whereas the injury rate is mini-
mal in others, such as golf, boating, cycling, equestrian, fishing,
parachuting, or bowling.
Etiology
The risk of sustaining an injury in a given sport may depend on
different factors such as velocity, exposure to other players or
obstacles, playing environment, training techniques, and equip-
ment. These are among some of the extrinsic factors, whereas
the individuals physical and personality traits constitute the intrin-
sic factors.
27
The factors most associated with injuries to the foot
Chapter 8a Sport-related injuries 333
A B
Figure 8a.1 Stress fracture metatarsal V (Jones fracture). (A) Stress fracture of the fifth metatarsal in a basketball athlete (symptoms: chronic
pain on the lateral aspect of the midfoot and sport disability after 5 months of conservative treatment). (B) Surgical treatment with open reduction
and internal fixation (intramedullary compression screw).
and ankle in sports include anatomic or biomechanical abnormal-
ities, lack of flexibility, poor strength, muscle imbalance, type of
shoe and/or use of orthoses, and type of playing surface.
26,27
Anatomic/biomechanical abnormalities
Various anatomic conditions have been frequently associated
with athletic injuries: Alignment of the lower extremity and/or
over-pronation has been associated with injuries to the knee,
ankle, and foot, and foot configuration has been associated
with stress fractures of the lower extremity (Fig. 8a.2). The belief
that runners who over-pronate initially have a higher risk of
sustaining a running-related injury is still held by most runners
and their coaches, although no reliable study has supported this
assumption. Probably the most comprehensive study of running-
related injuries, the Ontario cohort study, showed that none of
the anthropometric variables, such as femoral neck anteversion,
knee and patella alignment, rearfoot valgus, pes cavus/planus,
and running shoe wear pattern, was significantly related to risk.
136
Foot and ankle injuries in dancing such as ankle sprains, fatigue
fractures, or tendon ruptures have been related to poor technique
and malalignment.
19,32,66,82
Kinetic chain dysfunctions of the foot
have been described in dancers secondary to primary injuries.
82
Indeed, anatomic/biomechanical alterations appear to be
causally related to injury. Busseuil et al and other reports have
Table 8a.1 Foot and ankle injury rates in high-risk sports: a literature review
Sport First author Year Skill level Ankle injury Foot injury
Ballet Garrick
43
1986 Various levels 17% 22%
Basketball Henry
56
1982 Professional 18% 6%
Zelisko
143
1982 Professional 19% 4%
Prebble
104
1999 Various levels 33% NA
Dance Washington
137
Rovere
112
1983 Students 22% 15%
du Toit
33
2001 Various levels F&A 33%
Football Moretz
91
1978 High school 31% 8%
Ice hockey Sutherland
127
1976 Amateur 0% 0%
High School 0% 0%
College 7% 10%
Professional 0% 0%
Park
101
1980 Junior 4% 1%
Mountaineering McLennan
86
1983 NA 41% 8%
Tomczak
131
1989 NA 40% 35%
Orienteering Johansson
71
1986 Elite 26% 13%
Hintermann
60
Running Gottlieb
50
1980 Recreational 19% 11%
Temple
129
1983 NA 26% 26%
Marti
85
1988 NA 30% 10%
Walter
136
Bishop
12
1999 Professional 36% NA
Skating (ice) Smith
123
1982 Age 11-19 yr 29% 8%
Brown
18
1987 National males 8% 8%
Snowboarding Pino
103
Bladin
15
Bridges
17
Soccer Ekstrand
34
1983 Swedish senior division 17% 12%
Nielsen
95
Berger-Vachon
9
1986 French amateur leagues 20% NA
Woods
141
2003 Professional 11% NA
Squash/racquetball Berson
10
Soderstrom
124
1982 NA 20% 7%
Volleyball Schafle
117
1990 National amateur 18% 6%
Solgard
125
1995 Various levels 31% NA
F&A, foot and ankle; NA, not available.
Adapted from Clanton TO, Wood RM: Etiology of injury to the foot and ankle. In JC DeLee, D Drez, MD Miller, eds: Orthopaedic sports medicineprinciples and practice. Philadelphia,
2003, W.B. Saunders, pp. 2224-2274.
shown that hindfoot valgus correlates with a higher risk for foot
and ankle injuries.
22,27,58
The use of inverting shoe orthotics in
athletes with over-pronation may significantly prevent overuse
foot and ankle injuries.
27,58,140
Flexibility and stability
Lack of flexibility as a result of limited joint motion is a common
cause of injuries to the foot and ankle. Restricted dorsiflexion
at the ankle joint is a factor in the anterior ankle pain (soccer
ankle) often seen in soccer players that is associated with anterior
tibial osteophytes and/or a meniscoid lesion.
37
Two different
hypotheses have been described to explain the formation of
talotibial osteophytes in the anterior ankle impingement syn-
drome: hyperplantar flexion vs. recurrent ball impact. In a bio-
mechanical study, however, Tol et al
130
supported the hypothesis
that spur formation in anterior ankle impingement syndrome
is related to recurrent ball impact, which can be regarded as
repetitive microtrauma to the anteromedial aspect of the ankle.
In addition, other problems around the foot and ankle,
including turf toe,
25,111,138
bunions,
6
midfoot strain and plantar
fasciitis,
5,28,108,109
ankle sprains,
36,44,65
Achilles tendonitis,
139
calf
strains,
1,34
and hyperpronation
22,27,58
are believed to be due to
restricted ankle dorsiflexion. Although these conditions have
been related to a tight Achilles tendon, however, no study has
yet confirmed such an association.
A deficit of dorsiflexion at the first metatarsophalangeal joint,
as is typically the case in hallux rigidus,
83
has been related to turf
toe injuries.
25,138
Limitation of motion at the interphalangeal
joint is often connected to deformities such as hammer toe or
mallet toe and thus creates a problem.
24
On the other hand, hypermobility can cause injury problems
also at the foot and ankle. The hypermobility syndrome has been
described as a potential source of musculoskeletal symptoms.
27
In most cases this syndrome has no association with connective
tissue disorders, including Down syndrome, Marfan syndrome,
Ehlers-Danlos syndrome, and osteogenesis imperfecta. In certain
sports, however, high flexibility is needed. Ballet dancers, divers,
and gymnasts are particularly noted for the tremendous mobility
in their feet and ankles that allows them to achieve maximum
plantar flexion so that the foot is parallel to the lower leg.
Although such increased mobility has obvious advantages, an
increased incidence of injury was noted in those ballet dancers
who have greater mobility.
78
Alternatively, maximum plantar
flexion can create posterior ankle pain from impingement.
A pathologic increase in joint laxity, ankle instability
27,62
is
seen commonly in a few high-risk sports activities such as soccer,
basketball, orienteering, and others (Table 8a.1). Instability in
the ankle joint can be classified as lateral, medial, or rotational
instability and as acute or chronic. Chronic ankle instability
(CAI) has become very epidemiologically important in sports
medicine and orthopedics in recent years, leading to increased
health care costs and risk of posttraumatic osteoarthrosis of
the ankle.
53,54
It is well known that ankle sprains are among the
most common injuries occurring during sports activities,
44
caused
in 85% of the cases by an inversion trauma.
4
More than 23,000
ankle sprains occur per day in the United States.
74
Although
most of these ligamentous ankle injuries can be treated success-
fully with physical rehabilitation and nonoperative treatment,
20% to 40% of patients with ankle injuries go on to experience
CAI and subsequent disability.
16,40
The most common predisposition factor for CAI seems to
be the history of having suffered an ankle sprain in the past.
36,142
The pathomechanism involved in CAI may be mechanical insta-
bility
133
(posttraumatic ligament laxity, intraarticular pathologies,
altered joint mechanics), functional instability
40,41,57
(proprio-
ception, neuromuscular control, or strength deficit), or a combi-
nation of both.
133
Concerning the link between proprioception
and neuromuscular joint control, it has been demonstrated that
CAI leads to deficits in ankle proprioception, nerve conduction
velocity, neuromuscular response times, postural control, and
strength. Evidence suggests that alteration in muscle-spindle
activity of the muscles stabilizing the ankle may be more impor-
tant than altered articular mechanoreceptors.
76
Strength reduc-
tion for eversion and inversion has been described.
55,73
Strength
The belief that weak musculature predisposes an individual to
sports injury has been supported by various studies. Soccer play-
ers who sustained a minor injury during the preceding 2 months
with subsequent inadequate rehabilitation and poor muscle
strength had a 20% increase in risk for a more serious subsequent
injury.
34,36
Among 1139 young soccer players, 216 injuries,
most involving the ankle joint, were observed during a summer
training camp.
3
The highest incidence of injury occurred in boys
who were tall and had weak grip strength, which suggests that
skeletally mature but muscularly weak players were at increased risk
for injury as compared with their peers. Other studies concluded
that strength differences of more than 10% between the right
and left legs increases the risk for injury.
8,20
This finding corre-
sponds to the observation that the institution of a prophylactic
program, including rehabilitation to the point that 90% of mus-
cle strength had been regained, reduces the incidence of injury
in soccer players by 75%.
35
Other studies also have shown that
improving strength can reduce the risk for reinjury.
2,34
Chapter 8a Sport-related injuries 335
Figure 8a.2 Foot and ankle overload injuries. Foot and ankle
overload injuries (stress fractures, tendonitis, and others) are very
common in endurance sports, as marathon running. (Picture: IronMan
Triathlon, Zrich, Switzerland, 2003.)
Shoe wear and orthoses
Foot fixation on a playing surface resulting in abnormal torque
is the most commonly cited etiologic factor for noncontact
injuries to the knee and ankle.
27
Obviously dependent on the play-
ing surface, these injuries are often attributed to the shoe-surface
interface. This aspect is discussed in a later section.
A shoe that is fitted improperly and overly high causes
pressure-related pain at the site of bunions and bunionettes.
As examples, one can see aggravation of a bunion in a metatarsus
primus varus or an accessory navicular from an ice skating boot
and irritation of the Achilles tendon from many varieties of
shoe wear. It could be that local pressure at the heel may in some
C
A
B
D
Figure 8a.3 Fracture of the lateral process of the talus (LPT): snowboarders ankle. The LPT fracture is a snowboarding-specific foot and ankle
injury that can easily be missed by being considered a simple ankle sprain. The most frequent injury mechanism is a combination of axial impact,
dorsiflexion, external rotation, and eversion. Early and appropriate treatment based on fracture type may determine the outcome. (A) Acute lesion
with swelling and beginning hematoma. (B) Computed tomography with imaging of the displaced LPT fracture. (C) Intraoperative situs after removal
of the LPT fragment (D) in preparation for internal fixation with two screws.
cases produce retrocalcaneal bursitis.
139
The painful irritation of
the retrocalcaneal bursa often seen in runners and cross-country
skiers,
61
however, is likely to be caused less by an improperly
fitted shoe heel than by friction resulting from gliding of the
tendon over the posterior calcaneal bone due to eversion-inversion
movement of the calcaneus.
61
When the shoe is too short, the
toes jam into the end and nail problems occur; a shoe that is too
loose allows the foot to slide, and blisters result.
A lack of cushioning and/or support by the shoe has
been implicated also as a specific factor in overuse injuries.
96,97
Whereas some reports have shown beneficial effects of cushi-
oned shoes in reducing injuries,
94,119
other studies have been less
conclusive or have shown no benefit from increased shock
absorption in either shoes or insoles.
42,87,89
The authors hypothe-
size that excessive cushioning can actually be an etiologic factor
in injury by dampening the bodys own sensory feedback
mechanism coming from the plantar surface of the foot, a
pseudo-neurotropic effect that has been shown by other
authors as well.
110
The importance of proper shoe equipment is exemplified by
snowboarding over the last decades. One of the main reasons for
increase of foot and ankle injuries and fractures of the lateral
process of the talus (LPT) among snowboarders was the snow-
boarding shoe-binding equipment
23,29,77
(Fig. 8a.3). According to
Kirkpatrick et al,
77
LPT fractures occurred in 63% of their observed
cases in soft boots, 23% in hard boots, and 14% in hybrid boots.
They further showed, however, that most riders use soft boots
(78%), followed by hard boots (15%), and hybrid boots (7%),
77
perhaps explaining the increased incidence of the LPT fractures
using soft boot technology.
135
Torque is one of the most dangerous forces to which the body
is subjected in sports.
27
Cleating of the athletic shoe is designed
to improve traction for more efficient performance but can
significantly contribute to rotational load.
118
The number,
length, and pattern of the cleats
132
as well as the outsole material
and sole pattern
106
have been shown to influence traction
substantially. In a high school football program that has been
studied, the number of ankle injuries was halved by changing
from the traditional seven-cleated grass shoe to a soccer-style
shoe.
113
On the other hand, a lack of traction can potentially
cause injury by increasing the frequency of slips and falls.
27
In one study, for example, slipping on wet tennis surfaces was a
factor in 21% of injuries.
11
Obviously, superior performance
demands maximum traction, but at some point this can exceed
the bodys ability to handle the load.
Playing surfaces
Resurfacing and maintaining grass practice and game fields can
reduce injury rates about 30%.
93
Several studies of soccer,
64
dance,
45
and ice hockey
120
indicated also that the playing
surface is a factor relevant to injury. In softball, Janda et al
69
found that the main recreational injuries were related to sliding
into fixed bases. They showed that reduction of serious injuries
could be obtained by using breakaway bases, which demon-
strates also a potential for significant savings in medical care
costs.
68,70
In running, however, although the opinion is widely
held that hard surfaces and hills are big factors in injuries,
several studies did not prove a relationship between surface and
injury.
81,136
Prevention
As mentioned in the preceding section, analysis of risk factors
sometimes makes it possible to intervene in a way to reduce or
eliminate the risk factor and thereby lower the risk for injury.
This is indeed the aim of preventive sports medicine. Examples
of such intervention include rule changes in football to eliminate
the crackback block
102
and improved generations of synthetic
grass and underpadding brought about by research into the
relationship between artificial turf and injury.
79,122
In softball and
baseball, interventions such as breakaway bases, batting helmets,
face shields on helmets, lighter mass balls, and teaching and
reiteration of the fundamentals of softball and baseball all have
been effective in preventing millions of injuries and billions
of dollars in health care costs each year in the United States.
68
During a 3-year follow-up in junior elite cross-country skiers, the
prevalence of overuse injuries to the lower extremity decreased
from 62% to 22% when individual shoe adaptations and/or
orthotic devices were made.
59
Supervision by a doctor and phys-
iotherapist;
35
reduction in muscle tightness;
34
use of shock-
absorbent insoles,
94,119
orthotic devices,
121
external support
75
or
prophylactic ankle taping;
99
and injury prevention through bare-
foot adaptations
110,126
are among some of the preventive means
to reduce injuries to the foot and ankle.
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Anatomy and
Biomechanics of the
Ankle and Foot
Victor Valderrabano and Beat Hintermann
FUNCTIONAL FOOT AND ANKLE ANATOMY
A part of the lower extremity, the foot (pes), consists of 28 bones
(Fig. 8b.1): 7 tarsal bones (talus, calcaneus, navicular, cuboid,
medial, intermediate, and lateral cuneiforms), 5 metatarsal bones,
14 phalanges (two phalanges of the great toe, the other toes each
three phalanges), and 2 sesamoid bones at the first metatar-
sophalangeal joint. The skeletal framework of the foot is divided
into the tarsus (seven irregular bones), which is often subdivided
into midfoot (navicular, cuboid, and the three cuneiforms) and
hindfoot (calcaneus and talus). A total of 13 tendons crosses the
ankle joint (extrinsic muscles) and inserts at a bone of the foot.
Many more intrinsic muscles originate and insert within the foot
itself. Over 100 ligaments are described in the foot and ankle,
where they act as static stabilizers of the complex interplay of
all the foot and ankle joints.
C HA P T E R
8b
OSTEOLOGY
Talus
The talus consists of a body (corpus tali), a neck (collum tali), a
head (caput tali), two processes (posterior and lateral talus
processes), and a trochlea tali. The trochlea tali is wider anteriorly
than posteriorly, which stabilizes the bony ankle mortise in
dorsiflexion. The talus further shows a conic shape with radius
smaller on the medial side than the lateral side, allowing the
movement transfer from the foot to the lower leg and vice versa.
In a cadaver study of 100 specimens, Inman
29
determined that the
medial angle of orientation of the talus (medial facet) measured
83.9 degrees with a range of 70 to 90 degrees. The lateral angle
of orientation (lateral facet) formed a lateral angle averaging 89.2
degrees with a range of 80 to 95 degrees. From this data, Inman
determined that the talus is not a cylinder but rather a section of
a frustum of a cone, the apex of which is directed medially.
Unique for the talus is its being covered by cartilage on two
thirds of its surface and its having no muscular attachments. The
inferior surface of the talus rests on the sustentaculum tali of the
calcaneus, whereas anteriorly the bone articulates with the navic-
ular. The talus articulates with the tibia and fibula in the ankle
mortise (talocrural joint) and with the calcaneus (subtalar joint)
and navicular (talonavicular joint) distally. The blood supply of
the talus is performed by the posterior tibial artery (branch to the
tarsal canal, branches to the deep fibers of the deltoid ligament),
the anterior tibial artery/dorsalis pedis artery (branches to the
neck, branch to the sinus tarsi), and the posterior peroneal artery.
Calcaneus
The largest bone of the foot, the calcaneus (heel bone) projects
posterior to the ankle joint to provide leverage for the triceps
surae muscle group and origin for the plantar fascia. The lower
surface of the posterior end of the bone (tuber calcanei) has
rounded medial and lateral processes that provide contact surfaces
during locomotion. Anteriorly the calcaneus articulates with
the cuboid, and superiorly and medially the sustentaculum tali
supports the talus at the subtalar (talocalcaneal) joint.
Navicular
The navicular lies anterior to the talus on the medial side of the
foot. It articulates proximally to the talus with an oval-concave
articular surface, distally with the three cuneiform bones,
and laterally with the cuboid. The navicular tuberosity serves
plantar-medially as insertion structure for the posterior tibial
tendon.
Cuneiform bones (medial, intermediate,
and lateral)
Lying in a series across the anterior surface of the navicular,
the cuneiform bones articulate with the cuboid and the first three
Lateral
Phalanges
Metatarsals IV
Cuboid
Calcaneus Talus
Navicular
Intermediate
Cuneiform
Medial
I
II III
IV
V
Figure 8b.1 Bones of the foot. The foot consists of 7 tarsal bones
(talus, calcaneus, navicular, cuboid, medial, intermediate, and lateral
cuneiforms), 5 metatarsal bones, 14 phalanges (two phalanges of the
great toe, the other toes each three phalanges), and 2 sesamoid
bones beneath the first metatarsophalangeal joint.
metatarsal bones. The medial cuneiform serves on its dorsal
aspect as insertion structure for the tibial anterior tendon.
Cuboid
The cuboid articulates posterior with the calcaneus, anteriorly
with two lateral metatarsal bones, and medially with the lateral
cuneiform. On the medial side the cuboid shows a groove for
the peroneus longus tendon.
Metatarsals
The metatarsals are long bones that each have a base, body, and
head giving rise to five rays that culminate in a toe. The five
metatarsal are numbered from medial to lateral I-V. The first
metatarsal has a distal plantar cristae that articulates with the
two sesamoids: the fibular/lateral and the tibial/medial sesamoid.
Phalanges
The toes consist of short phalangeal bones: proximal, middle,
and distal in the four lateral toes and proximal and distal in the
hallux.
ARTHROLOGY
Ankle joint
The ankle or talocrural joint consists of the bony articulation of
the distal tibia (tibial plafond), the medial malleolus and lateral
malleolus (fibula), and the dome of the talus. The ankle joint
is stabilized by several ligaments: the deltoid ligament (medial
collateral ligament; complex arrangement of several ligaments
in a deep and superficial layer
6
), the lateral collateral ligament
complex (anterior talofibular ligament, calcaneofibular ligament,
and posterior talofibular ligament), the anterior and posterior
inferior tibiofibular ligament, the transverse tibiofibular ligament,
and the interosseus ligament.
Close
11
found the deltoid ligament to be a strong restraint
limiting talar abduction. With all lateral structures removed,
the intact deltoid ligament allowed only 2 mm of separation
between the talus and medial malleolus. When the deep deltoid
ligament was released, the talus could be separated from the
medial malleolus by a distance of 3.7 mm. The tibiocalcaneal
ligament (the strongest superficial ligament) specifically limits
talar abduction, whereas the deep portions resist more external
rotation as well.
16,61,62
In dorsiflexion, the posterior talofibular ligament is maximally
stressed and the calcaneofibular ligament is taut, whereas the
anterior talofibular ligament is loose. In plantar flexion, however,
the anterior talofibular ligament is taut, and the calcaneofibular
and posterior talofibular ligaments become loose.
13,63,70
Some
variation of this tension pattern is allowed by the different
patterns of divergence between the anterior talofibular and calca-
neofibular ligaments.
Subtalar joint
The subtalar or talocalcaneal joint consists of the bony articula-
tion of the talus and calcaneus building the posterior, medial,
and anterior joint facets. The posterior facet is larger than the
anterior and middle facets, is convex in shape, and articulates
with the talar body. Situated on the sustentaculum tali, the
middle facet is slightly concave. The anterior facet is concave
and normally located just lateral to the middle facet. The middle
and anterior facets articulate with the talar head. Between the
posterior facet and the anterior and middle facets lies the tarsal
canal, which opens broadly laterally and forms the sinus tarsi.
The subtalar joint is stabilized by four ligaments, both intrinsic
and extrinsic.
71
The intrinsic ligaments are the interosseus talo-
calcaneal ligament, which fills the tarsal canal, and the cervical
ligament (bifurcated ligament), which fills the sinus tarsi. Both
the interosseus talocalcaneal ligament and cervical ligament can
be injured in lateral ankle sprains or aggravated by conditions
such as inflammatory arthritis, leading to subtalar instability.
42
The extrinsic ligaments of the subtalar joint are the calcaneo-
fibular ligament, the lateral talocalcaneal ligament (beneath
the calcaneofibular ligament), the tibiocalcaneal ligament (super-
ficial deltoid), the medial talocalcaneal ligament (medial talus
tubercle-sustentaculum tali), and the posterior talocalcaneal
ligament (lateral talus tubercle-posterior calcaneus).
Transversal tarsal and tarsometatarsal joints
Choparts joint is the transversal tarsal joint built proximally by
the talus and calcaneus and distally by the navicular and cuboid.
Important ligaments within and around this joint are the plantar
calcaneonavicular ligament (spring ligament; coxa pedis), the
calcaneonaviculocuboid ligament (bifurcated ligament), the dor-
sal talonavicular ligament, and the dorsal and plantar calca-
neocuboid ligaments.
Lisfrancs joint is the tarsometatarsal joint between proxi-
mally the cuneiforms and cuboid and distally the basis of the
five metatarsals.
59
The tarsometatarsal joints are stabilized by
dorsal, plantar, and interosseus ligaments. The Lisfranc ligament
is a strong plantar ligament that connects the medial cuneiform
to the base of the second and longest metatarsal bone. In about
20% of patients, two separate bands of the Lisfranc ligament
(dorsal and plantar) are present. Between the bases of the first
and second metatarsals there are no ligaments, creating a relative
weakness between the first and the other metatarsals.
Another important midfoot and arch stabilizer is the plantar
aponeurosis (also called plantar fascia). A strong fibrous
tissue, the plantar aponeurosis has three components: central,
medial, and lateral. The plantar aponeurosis arises from the os
calcis and inserts into the metatarsals and the plantar aspects of
the toes, making possible the windlass mechanism described by
Hicks.
23
Metatarsophalangeal joints
The metatarsophalangeal joint of the hallux is different from
those of the other toes by the sesamoid mechanism. Here the
Chapter 8b Anatomy and biomechanics of the ankle and foot 342
sesamoids articulate on their dorsal surfaces with the medial
and lateral facets on the plantar aspect of the first metatarsal
head. An intersesamoidal ridge (crista) separates these facets.
The two sesamoids, lateral and medial, are incorporated into
the two tendons of the flexor hallucis brevis. The first
metatarsophalangeal joint is further stabilized on the plantar
medial and lateral side by the fan-shaped collateral ligaments
and sesamoidal ligaments. The hood ligaments of the extensor
expansion and the capsule form the stabilizing structures
dorsally.
FOOT ARCHES
Morphologically, the foot may be described as having three
arches. Longitudinally, the arch of the foot is higher on the medial
than on its lateral side. The former involves the calcaneus, talus,
navicular, cuneiforms, and three medial digits; the latter, although
also arising from the calcaneus, proceeds through the cuboid
and two lateral digits. In the midfoot region, the arch in the
transverse plane is observed passing through the talus and navic-
ular on the medial side to the calcaneus and cuboid on the lat-
eral side. This arch gradually flattens anteriorly so that the heads
of the metatarsal bones are all in the same plane. The arches are
dynamically maintained by the following:
The keystone effect of the talus, cuboid, and middle cuneiform

within the medial, lateral, and transverse arches, respectively.
The articular surfaces of these bones form a wedge that drops
into place between adjacent bones.
The bowstring effect of the plantar ligaments. The plantar

calcaneonavicular (spring) ligament maintains the medial
arch, whereas the short and long plantar ligaments maintain
the lateral arch.
The intrinsic and extrinsic muscles of the foot, which assist in

maintaining the arches.
Morphologically, it is convenient to describe the foot in
terms of three discrete arches; however, when forces distributed
throughout the foot are considered, there is a complex interplay
of stresses that acts among all the components of a single
dynamic structure. Clinically-morphologically and based on
plantar pressure assessment, the human arch can generally be
described as normal, high (pes cavus), or flat (pes planus)
(Fig. 8b.2).
BIOMECHANICS OF THE FOOT AND ANKLE
The foot is a specialized organ with the following contrasting
characteristics (Fig. 8b.3):
Support of body mass;
Static and dynamic balance;
Facilitation of locomotion.
These characteristics are achieved by large muscles located
in the shank, smaller intrinsic muscles of the foot, bony levers,
and various degrees of joint mobility within the foot and ankle.
Adequate muscular development and joint function are essential
for normal gait and foot mechanics.
Measurement of foot and ankle movement
The ankle joint complex allows for relative movement between
the foot and the leg. The following paragraphs concern possibil-
ities to assess this movement, specifically addressing the clinical
and functional assessment and the three-dimensional assessment.
Clinical and functional assessment
Rotational movement between two segments occurs around a
momentary axis of rotation determined primarily by the shape,
the ligamentous structures, and the muscle-tendon units of
the joint. Rotations describing the functional movement of two
adjacent segments are those occurring around functional axes.
The ankle joint complex is a peculiar joint in the sense that
during locomotion one can estimate the location of two of the
three bones that make up the joint, the tibia, and the calcaneus.
It is practically impossible, however, to estimate the location
of the talus during locomotion. Additionally, it is extremely dif-
ficult to determine the ankle joint axes
87
around which the actual
rotational movements occur. Consequently, it is difficult to
describe the movement of the ankle joint complex by using
functional axes. Movement of the foot, however, can be deter-
mined much more easily in a clinical environment by defining
foot axes such as the anteroposterior, the mediolateral, and the
inferosuperior axes.
Movement of the foot can be defined with respect to the
direction of locomotion,
58
the position of the foot with respect
to a laboratory coordinate system, or the position of the foot
with respect to the leg. Specific descriptions of foot movement
may be advantageous for specific questions. Foot movement with
respect to the direction of movement of the center of mass may
be appropriate for energy considerations. Foot movement rela-
tive to the leg may be appropriate for local loading aspects.
83-85
In any case, it is crucial to define the system of reference clearly,
because the results depend on it.
Three-dimensional assessment
The rapid development of technology has provided gait analysis
systems offering the possibility for three-dimensional movement
analysis.
58
This development is not without concerns, two of
which, the use of two-dimensional analysis and the sequence
of angle determination, are discussed shortly.
For many questions, a two-dimensional approach is appro-
priate, and errors resulting from these restrictions are minimal. It
is therefore appropriate to first check whether three-dimensional
analysis is really necessary and what errors occur by changing to
two-dimensional analysis.
A three-dimensional rotational movement subdivided into
its three rotational components provides different results
depending on the sequence of the rotations chosen.
1
One can
easily verify this by moving the arm from an initial position
where the arms are alongside the body with the palms facing
its sides to a final position where the arm points horizontally
at a 45-degree angle from the sagittal plane and the palms face
the sides. The angular components used are extension, abduc-
tion, and axial rotation. One may reach the final position by first
moving the arm upward and second by abducting it 45 degrees.
This would correspond to an FL-abduction-axial rotation
sequence with the values 90-45-0 degrees. One may reach the
Chapter 8b Biomechanics of the foot and ankle 343
same final position, however, first by axially rotating the arm
45 degrees and second by extending the arm 90 degrees. This
corresponds to an axial rotation-FL-abduction sequence with
the values 45-90-0 degrees. Both movement sequences include
90 degrees of extension. The first movement sequence, however,
includes 45 degrees of abduction and no axial rotation, whereas
the second movement sequence includes no abduction but
45 degrees of axial rotation. It is therefore important to under-
stand for which movement analyses the sequence of the angular
components is crucial.
D
B
C
A
Figure 8b.2 The dynamic pedobarography (A) allows an objective and accurate assessment of the plantar pressure distribution (system used
here: Emed, Novel, Munich, Germany). Variables such as contact area, peak forces, and center of pressure (COP) can be evaluated graphically
and numerically. (B) The feet of a subject with normal arch; (C) the feet of a subject with a high arch (cavus foot); (D) the feet of a subject with
a flatfoot deformity.
Many authors have argued about the appropriateness of some
of the sequences.
1,17
However, logical arguments described earlier
54
that have used anatomic definitions of flexion-extension, abduc-
tion-adduction, and axial rotation indicate that the appropriate
sequence in agreement with the definition of these movements
for all human joints is as follows:
In general For the ankle joint complex
Flexion-extension Plantar flexion-dorsiflexion
Abduction-adduction Abduction-adduction
Axial rotation Inversion-eversion
ANKLE JOINT COMPLEX MOTION
Anatomic and biomechanical studies indicate that the ankle
moves not as a pure hinge mechanism
2,22,26,39
but rather in the
sagittal, coronal, and transverse planes.
39,41
Rotational axis and movement
transfer of the ankle joint
An early anatomic study pointed out that the wedge of the
talus and the differing medial and lateral talar dome radii of
curvature implied that tibiotalar congruency could not be
maintained through sagittal motion unless the talus exhibited
coupled axial rotation.
2
The joint axis tends to incline down
laterally when projected onto a frontal plane and posterolaterally
when projected onto a horizontal plane.
3,29,39
Because of this
oblique orientation, dorsiflexion of the ankle results in eversion
of the foot, whereas plantar flexion results in inversion. When
the foot is fixed on the ground, dorsiflexion causes internal rota-
tion of the leg, and plantar flexion causes external rotation.
2,7,24,38,
67,73,84,93
This has been substantiated in kinematic tests of loaded
cadaver ankle specimens.
47,84
Having studied sagittal plane motion relative to the tibiotalar
joint surface, Sammarco
67
explained that the motion between
the tibia and talus takes place about multiple instant centers of
rotation. Ankles taken from plantar flexion to dorsiflexion showed
a tendency toward distraction early in motion, followed by a
sliding movement through the midportion that ends in compres-
sion at the end of dorsiflexion. This process was reversed when
the joint was moved in the opposite direction. Locations and
patterns of instant centers varied among different individuals,
direction of motion, weight-bearing states, and pathologic states.
An unstable ankle demonstrated normal gliding during weight
bearing, but non-weight-bearing motion was grossly abnormal.
Using stereophotogrammetry, Lundberg et al
39
performed a
three-dimensional evaluation of the joint axis in eight healthy
ankles. They explained that talar rotation occurs about a dynamic
axis during sagittal plane movement of the ankle, which in each
subject lay close to the midpoint of a line between the tips of the
malleoli. Plantar flexion axes were more horizontal and inclined
down and medially compared with those of dorsiflexion. Most
interestingly, no frontal plane movement occurred between the
talus and the tibia during inversion/eversion of the loaded foot
within a physiologic range of motion.
Van den Bogert et al
87
showed a subject-specific three-
dimensional model of the ankle joint complex for calculation
of the ankle and subtalar joint axis. The talocrural and subtalar
joints were modeled as a three-segment system connected by two
ideal hinge joints. A mathematical formulation was developed to
express the three-dimensional translation and rotation between
the foot and shank segments. Their results showed that the
lateral side of the talocrural axis was directed slightly posterior
(6.8 8.1 degrees) and inclined down by 7.0 5.4 degrees.
Further, they showed that the inclination of the subtalar joint
axis from the horizontal plane was 37.4 2.7 degrees and the
medial deviation was 18.0 16.2 degrees.
Leardini et al
31
developed a mathematical model to explain
the multiaxial motion of the ankle in the sagittal plane. These
authors described a four-bar linkage model showing the
talus/calcaneus and tibia/fibula rotating about one another on
inextensible line segments that represent the calcaneofibular
and tibiocalcaneal ligaments without resistance. Motion between
the polycentric polyradial trochlea consisted of a combination
of rolling and sliding motions. In this model, rotation is
dictated by the most anterior fibers of the anterior talofibular and
calcaneofibular ligaments. Leardini
30
later observed that these
specific fiber bundles were isometric through the range of sagittal
motion of the ankle. The instant center of rotation translates from
a posteroinferior to a superoanterior position, a finding consistent
with several studies suggesting that the ankle is incongruent and
rotates about a transient center.
68,69,73
The complex and dynamic
nature of the ankles axis of rotation may be one reason for poor
results in total ankle replacement surgery and has important
implications for the design of total ankle prostheses.
Ankle range of motion
Overall values found in the literature for normal range of motion
in the ankle range from 23 to 56 degrees of plantar flexion
and from 13 to 33 degrees of dorsiflexion
22,34,35,38,50,64,66,78,84,92,93
(Fig. 8b.3C and 8b.3D). Ten to 15 degrees of plantar flexion
and 10 degrees of dorsiflexion are used during walking.
66
About
14 degrees in range of motion are used in the stance phase of
gait, whereas 37 degrees are needed for ascending and 56 degrees
for descending stairs.
78
In the diseased ankle, dorsiflexion is
typically decreased and limits daily activities, especially in the
presence of pain. Ten to 15 degrees of dorsiflexion are all that
are needed for daily activities in patients who do not rely on
their ability to ascend and descend stairs.
39
The goal in total
ankle replacement should therefore be to provide a minimum of
10 degrees of dorsiflexion and 20 degrees of plantar flexion for
an appropriate push-off.
Several factors influence sagittal plane motion of the
ankle. Healthy older individuals demonstrate decreased plantar
flexion.
36,50,66
Sagittal motion (primarily dorsiflexion) has been
found to increase significantly by assessing subjects while bearing
weight as compared with passive measuring.
35,64
Rotation of the ankle in the transverse plane is usually
reported relative to instability,
43,79
but transverse plane motion is
coupled with that in the sagittal plane.
11,37,39,46,66
Transverse plane
motion is noted also during normal gait.
11,37,38,73
Lundberg et al
39
Chapter 8b Ankle joint complex motion 345
observed 8.9 degrees of external rotation of the talus as the ankle
moved from neutral position to 30 degrees of dorsiflexion,
whereas a small amount of internal rotation occurred with
plantar flexion from neutral to 10 degrees followed by external
rotation at terminal plantar flexion.
38
Michelson and Helgemo
46
reported that dorsiflexion resulted in an average of 7.2 3.8 degrees
of external rotation of the foot relative to the leg with ankle
dorsiflexion and 1.9 4.12 degrees of internal rotation with
plantar flexion. In unloaded specimens, some coupling between
the ankle and subtalar joints was observed also with sagittal plane
motion.
73
With dorsiflexion, there was internal rotation at the
subtalar joint and external rotation at the ankle joint. The idea
that this coupling is caused by tensioning of the deltoid ligament
is supported by the findings of McCullough and Burge,
43
who described greater external rotation of the talus after deltoid
ligament sectioning.
A B
D C
Figure 8b.3 The function of the foot and ankle. The foot and ankle function mainly as a locomotion organ, allowing the plantigrade ambulation
and providing support of body mass and static and dynamic balance. Anterior view of the weight-bearing static position of both feet (A), lateral
view (B); plantar flexion of the ankle joint complex during heel rise test (C), dorsiflexion of the ankle joint complex during heel standing test (D).
Described as varus or valgus rotation, coronal motion may
also be described as inversion or eversion. Michelson et al
45
observed that plantar flexion of the ankle was associated with
internal rotation and inversion. They attributed coronal plane
motion to the position of the deltoid ligament, showing that after
progressive medial ankle destabilization, talar external rotation
and inversion increased.
Restraints of ankle motion
The stability and integrity of the ankle joint depends on articular
geometry and ligamentous attachments. Ankle ligaments have a
passive tracking and stability effect on the joint. On the medial
side, the strong deep deltoid ligament is a secondary restraint
against lateral and anterior talar excursion,
6,19,63
whereas on the
lateral side, the relatively weak anterior talofibular ligament is
the only restraint against anterior talar excursion.
32,48,63
The ante-
rior talofibular ligament is that which is most susceptible to
injury and subsequent insufficiency,
4
often leading to antero-
lateral dislocation of the talus out of the mortise and posterior
dislocation of the fibula, respectively. In such a case, reconstruc-
tion of the anterior talofibular ligament (or ligament balancing)
may be advised when unconstrained prostheses are used for total
ankle replacement.
Several studies
27,74
reported the effects of the lateral liga-
ments on axial rotation of the loaded ankle. Hintermann et al
27
observed that the rotation of the tibia occurring after sectioning
of the anterior talofibular ligament was more profound from
neutral to plantar flexion than that observed in 10 to 20 degrees
of dorsiflexion. When the deltoid ligament was sectioned, no
tibial rotation was observed. This finding is consistent with those
of Michelson et al,
44
whose report suggested a motion-coupling
role for the deltoid ligament in addition to stabilization.
During walking, rotation occurs about a vertical axis.
11,33
Rotatory stability is provided by tension in the collateral liga-
ments, by compression of the medial and lateral talar facets
against their corresponding malleoli, and by the shape of the
articular surfaces.
19,43,74,79
Because of the truncated conical shape
of the talus with its medially directed apex, the three separated
lateral ligaments control the greater movement on the lateral
side, whereas the deltoid ligament controls the lesser movement
on the medial side. This has important implications for ligament
balancing in total ankle replacement, because nonanatomic
prosthetic design and/or inappropriate implantation may pro-
voke medial ligament stress with consequent pain, posterome-
dial ossification, and loss of range of motion
82
or lateral ligament
insufficiency with consequent lateral ankle instability, respectively.
Stability in the loaded ankle depends on articular shape.
19,43,74,79
Stormont et al
79
performed serial sectioning of the ankle liga-
ments and subjected the ankle to physiologic torque and loads.
The articular surface accounted for 30% of ankle stability in
rotation and 100% of ankle stability in inversion and eversion.
In a similar study, McCullough and Burge
43
found that with
increased loading of the ankle, increased rotatory forces are
necessary to cause displacement. The congruity of the articular
surface of the ankle joint thus creates an inherently stable artic-
ulation with loading, and no ligamentous restraints exist in
inversion and eversion. The sole restraint of the joint under
loaded conditions is provided by the articular surfaces. This
has important implications in the design of total ankle prosthe-
ses and may explain poor results with prosthetic designs that
expose the ankle ligaments to eversion and inversion forces
while the ankle is loaded.
84
During most activities, the soft
tissues are the major torsional and anteroposterior stabilizers
of the ankle,
8,9
whereas its articulating surface geometry is the
major inversion/eversion stabilizer, with collateral ligaments
playing a secondary role.
43,79
INTERNAL FORCES AND CONTACT AREA
External forces acting on the human foot, geometric alignment
of the foot and the leg, muscle forces, and segmental inertia
forces are responsible for the internal forces acting in joints
and on ligaments and tendons. Mathematical models are used
to estimate the magnitude of forces in internal structures such as
joints, tendons, and ligaments. These estimations use several
(sometimes different) assumptions that are still being discussed
in the literature.
21
However, the order of magnitude of the
estimated forces is assumed to be correct.
Typically, the geometry of the acting forces (the distance
from the line of action of an acting force to a joint of interest) is
the most important factor that determines the internal forces.
Technically, the internal forces in the anatomical structures of
the human foot can be either measured directly in vitro or cal-
culated from in vivo pressure distribution of the foot sole;
in most cases the pedobarography technique using pressure
distribution sensors is applied (Fig. 8b.2)
12,87
The results of
pressure distribution measurements have been used as localized
input into the different foot structures to provide a possible
means of quantifying internal forces in joints, ligaments, and
tendons of the foot, an estimation that cannot be performed
using the ground reaction force as input.
In the ankle joint, a vertical load of 5.2 times body weight
has been found during gait.
78
In diseased ankles, the joint load
decreased to approximately three times body weight, and the same
values have been noted in replaced ankles.
78
Anteroposterior
and lateral shear forces during gait have been estimated to reach
levels of two and three times body weight, respectively. With an
interface area of 7 cm
2
, the average compressive load per unit
area at the interface during gait would be approximately 3.5 MPa
in a person of 700 N body weight.
The complex geometry of the mortise and trochlea of the
talus influences load characteristics.
5,7,39,41,80
Reports of whole
ankle contact area vary from 1.5 to 9.4 cm
2
depending on load
and ankle position.
90
The tibiotalar area, however, accounts for
only approximately 7 cm.
2,78
Controversies exist about changes
in the contact area as a function of flexion position
5,7,41
that
may be attributed to differences in load, position, and measure-
ment technique.
32
Calhoun et al
7
found that contact surface area
increased from plantar flexion to dorsiflexion and that force
per unit area decreased proportionately. They observed also
that the medial and lateral facets had greatest contact with the
malleoli in dorsiflexion. In another study, using a dynamic
model, progressive lateral loading with concomitant medial
unloading was observed during dorsiflexion and associated
external rotation.
46
Chapter 8b Internal forces and contact area 347
Ground reaction and gravitational, ligament, and muscle forces
produce a mixture of three-dimensional compressive, shear, and
torsional loads in the ankle joint. Therefore, one may easily
assume that force may not necessarily be directly perpendicular
to the bone-implant interface but more angular. This introduces
shear forces in addition to those of direct compression.
GROUND REACTION FORCES AND
PRESSURE DISTRIBUTION
Whenever the foot is in contact with the ground, forces act from
the ground onto the foot and vice versa. These ground reaction
forces are resultant forces that correspond to the movement of
the center of mass and gravity. Typically subdivided into impact
and active forces, ground reaction forces are determined by
movement of the various segments involved in the locomotion
process. Among the axes of the xyz coordinate system, they can
be divided into the vertical, anteroposterior, and mediolateral
force. Different for various activities, ground reaction forces
can easily exceed body weight several times.
56
In normal walk-
ing the vertical ground reactive force shows a typical two-peak
active force pattern in a level around the body weight,
58
the first
peak associated with deceleration and the second with accelera-
tion. In running at a speed of 4 m/s, the vertical component of
the ground reaction force typically shows a single peak that
increases into about two to three times body weight.
56,58
As inte-
gral quantities, the ground reaction forces are limited in pro-
viding information on local phenomena, especially those
specific to the foot. Pressure distribution measurement over
the whole contact area of the foot sole provides more accurate
information.
Ground reaction forces and plantar pressure distribution can
typically be measured either by the Kistler force plate technique
(piezoelectric elements, as in the case of the classic motion
analysis) or by computerized pedobarography systems (Fig. 8b.2).
In the pedobarography (plates or insoles equipment, static or
dynamic measurement) many hundreds of small force plates
or sensors measure the force of the plantar aspect of the foot
perpendicular to the surface.
56,57,82,86
Compared with the Kistler
plate technique, pedobarography pressure distribution sensors
are better suited to provide more local information. Pressure
distribution sensors are used in the form of insoles to assess
foot-specific problems within the shoe, as in diabetic patients,
20
or in the form of plates to assess postoperative outcome after
orthopedic treatment, as in fracture reduction,
81
total ankle
replacement,
28,82
tendon rupture repair,
86
or fusion.
14
SHOE CONSIDERATIONS
The shoes main function is to protect the foot sole from the
hazards of the environment and furthermore to facilitate running,
to stabilize and treat foot deformities, and to serve as symbol
in the society and fashion world (Fig. 8b.4). Without shoes, the
foot has a natural ability to allow for torsional motion between
the hind- and forefoot. Shoes often have torsional stiffness
that decreases this physiologic movement. Studies have sug-
gested that low torsional stiffness is advantageous, especially
for movement involving landing on the forefoot as is typical in
volleyball or basketball.
75,77
It is believed, however, that excessive
cushioning found in modern shoewear prevents appropriate
sensory feedback and results in a pseudo-neurotropic effect in
running.
65
The sensibility potential of the foot sole is the main reason
that professional gymnasts and some dancers perform with no
shoes or minimally shod feet. Stacoff and Lthi
76
reported that
shoewear has been recorded as a source of injury since the early
Greeks. Having been the norm in ancient times, barefoot running
received international attention with Zola Budds 3000-m
Olympics participation in 1984 (www.runningbarefoot.org).
During barefoot running, the least amount of pronation and
therefore injuries occur.
75
Lysholm and Wiklander
40
showed in
60 runners with 55 injuries within 1 year that shoe and surface
problems were the primary sources of injury.
Considering that impact forces are the critical variable in the
pathophysiology of sports-related pain and injury,
51
however,
cushioning and shock absorption in sport shoes protect athletes
and military recruits from overload injuries.
15,49,72
By influencing
impact loads, shoe material properties affect exposure to injury, as
in cases of intraarticular cartilage damage and osteoarthritis.
60,88,89
Excessive ankle joint eversion has been typically associated
with the development of overuse injuries in locomotion.
10,18,91
Subjects with injuries typically have foot eversion movement
that is about 2 to 4 degrees greater than that of those with no
injuries. Further, it has been suggested that a combination of
excessive ankle joint eversion and substantial movement transfer
of foot eversion into internal tibial rotation is a good predictor of
the development of overuse injuries, especially in the knee.
25,26
It has been proposed that movement transfer between foot
eversion and tibial rotation is small for subjects with low arches
and high for those with high arches.
53
Consequently, subjects
with high arches and excessive ankle joint eversion are more
susceptible to overuse injuries.
Ankle joint eversion is substantially influenced by shoes.
Differences in ankle joint eversion for a subject using different
running shoes are considerable. It is easily possible that the
Figure 8b.4 Picture of a normal shoe (Kzli AG, Schuhfabrik,
Windisch, Switzerland).
maximal ankle joint eversion movement is 31 degrees for one
and 12 degrees for another running shoe.
52
Although medial support in a shoe may provide comfort and
increased stability to the foot and leg and may reduce maximal
ankle joint eversion, it may also increase internal rotation of
the tibia. It is assumed that this change is associated with an
increased inclination of the subtalar joint axis.
53
SHOE INSERTS AND ARCH SUPPORTS
Shoe inserts and foot arch supports are often used successfully in
the conservative treatment and prevention of occupational and
sports injuries. They limit overuse of the foot structures, increase
foot-leg stability, and/or change foot function. The prescription
of these aids is typically based on the clinical expertise of the
physician, plantar pressure distribution measurement (pedo-
barography), and plaster cast analysis or other moldings. Many
problems are treated successfully with these strategies. Possible
indications include tibialis posterior tendon dysfunction (stage I/II),
medial ankle instability, plantar fascitis, and forefoot metatarsal
collapse, among others. In most applications, however, the mechan-
ical functioning of such orthoses is not well understood.
In a recent biomechanical study involving lower extremity
kinematic, kinetic, and electromyographic analysis, Mundermann
et al
49
showed the importance of comfort in foot orthoses. They
concluded that evaluations of foot orthoses using comfort reflect
not only subjective perceptions but also differences in functional
biomechanical variables.
Prescription of inserts and/or orthotics is a difficult task, how-
ever, and the correlation of clinical, design, and biomechanical
variables is not well understood.
55
Further research is needed
to develop new measurement methods and to improve the
functional-mechanical understanding of shoe inserts and arch
supporting orthoses.
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Foot and Ankle Disorders
in the Workplace
Ross Taylor and G. James Sammarco
Workplace injuries of the foot and ankle represent a unique
set of challenges within occupational medicine. The average
adult takes approximately 7500 steps per foot in the course of
an average day. The foot may be subject to forces in excess of
twice body weight during routine activities. The workplace is
even more demanding with requirements for ambulation on
uneven surfaces, balancing on scaffolds, ladder climbing, and
carrying heavy loads commonplace. Although the foot and
ankle are supremely adapted to perform these functions, injuries
may make these routine occupational activities impossible.
Furthermore, underlying systemic conditions such as vascular
disease, diabetes, obesity, and tobacco abuse frequently compli-
cate the lower extremity injury or disease process and compound
diagnostic and treatment dilemmas.
Successful treatment begins with timely and accurate diag-
nosis. This requires not only skilled history taking but also a
solid fund of anatomic knowledge. An understanding of the
multitude of pathologic entities that affect the foot and ankle is
a prerequisite. The occupational medicine practitioner must rely
on this understanding to not only arrive at a working diagnosis
but to determine the contribution of nonoccupational factors in
the workers disease process. Once diagnosis has been established,
expeditious treatment is of paramount importance. Whenever
possible, the worker should be returned to modified duty during
the rehabilitation process to minimize the psychosocial impact
of occupational impairment.
It is hoped that the reader may take away from this chapter
an understanding of the broad spectrum of injuries to the foot
and ankle incurred in the workplace setting. All too often a
swollen and painful foot with negative radiographs is dismissed
as a sprain. Only when the patient fails to improve in a reason-
able period of time are additional possibilities considered. This
leads to an untold waste of human resources and is often avoid-
able were the treating practitioners more thorough in their
approach to injuries of the foot and ankle. This chapter is intended
to serve as a foundation of knowledge regarding workplace
injuries to the foot and ankle upon which successful diagnosis,
treatment, and return to work can be efficiently executed.
EPIDEMIOLOGY
The Bureau of Labor Statistics data indicate a total of 1.3 million
injuries and illnesses required recuperation away from work
beyond the day of injury in private industry in 2003.
25
Conditions
of the foot or ankle constituted approximately 125,000 of these
injuries or approximately 9.5%. Those involved in occupations
C HA P T E R
8c
related to trade, transportation, and utilities demonstrate the
highest number of foot and toe injuries, comprising 35% of
all foot and toe injuries recorded. Construction constitutes the
second most represented occupational category, recording nearly
16% of foot or toe injuries. Sprains and strains were the most
common type of injury of the ankle, constituting almost 70%
of all ankle injuries. On the other hand, fractures are the most
common nature of injury recorded in the foot or toes, compris-
ing 26% of such injuries. The most typical event leading to injury
was falling to a lower level for ankle injuries (20%) versus contact
with objects for foot injuries (86%). A contributing source of
injury is noted to be floors, walkways, or ground surfaces most
commonly for both foot (20%) and ankle (40%) injuries but
was more commonly found to be parts and materials (23%) for
toe injuries. The median number of days of work missed per
injury of the foot was seven days and for toe injuries, six days.
APPROACH TO THE PATIENT WITH
WORK-RELATED FOOT AND ANKLE INJURY
The first and perhaps most important step in returning the
injured worker to their preinjury status when possible is prompt
and accurate diagnosis. This is all too evident in cases in which
the initial diagnosis is incomplete or inaccurate, leading to the
initiation of incorrect or inadequate treatment. Subsequently,
physical therapy may be initiated when immobilization is more
appropriate or vice versa. The result of failure at the diagnosis
level is not only a disgruntled worker but also increased expenses
related to multiple referrals and time away from work. Accurate
diagnosis begins with a thoughtful history.
Often, the history is straightforward and that of traumatic
injury. For instance, a fall from a height with sudden onset of
heel or leg pain may suggest a calcaneus or distal tibia fracture.
Ankle sprain or fracture often occurs when the ankle is forcibly
rolled in inversion. Twisting of the ankle in external rotation
suggests high ankle sprain or ankle fracture. Midfoot fracture-
dislocation may occur with a crushing mechanism to the foot,
such as when heavy machinery rolls onto the foot or a large object
is dropped directly onto the foot. Metatarsal or toe fractures can
result when such a force is applied across the unprotected forefoot.
Hyperdorsiflexion of the toes may result in injury to the plantar
plate or cartilage of the hallux metatarsophalangeal (MTP) joint.
Certainly, traumatic injury simplifies history taking. When
the worker gives a history of onset of pain during routine activi-
ties, the differential diagnosis expands dramatically and the line
between work-related injury and a degenerative or inflammatory
disorder is less than distinct. More controversial is the role of
repetitive overuse in the work-related injury. Diseases such as
plantar fasciitis, hallux valgus, tarsal tunnel syndrome, interdigi-
tal neuroma, lesser toe deformities, adult acquired flatfoot,
and osteoarthritis may present in the workplace. Guyton et al
9
applied Kochs postulates to examine the possible relationship
between cumulative industrial trauma and causation of these
seven disorders but found no association. Nonetheless, these are
important disease entities that may be perceived as initiated by
work-related activities. In the interest of confining the scope of
this chapter to injuries of less controversial etiology, these
processes are excluded from this chapter.
Examination of the foot and ankle begins with observation
of the patient in the standing position whenever possible.
Overall alignment of the foot and ankle should be noted as well
as any asymmetry between sides. Swelling, edema, and ecchy-
mosis should be noted at this time, as well as any lacerations
or obvious abrasions. The position of the foot or ankle may
provide insight into the potential for injury to various structures.
For instance, accentuation of the longitudinal arch of the foot
(cavus foot) predisposes the worker to injuries over the lateral
side of the foot and ankle such as ankle sprain, peroneal tendon
tear, or fracture of the base of the fifth metatarsal. A flattened
arch may suggest medial ankle sprain or injury to the posterior
tibial tendon. Inspection of gait is fundamental as well, primarily
to note the presence or absence of shortening of stance (antalgia)
on the affected side. Careful range-of-motion assessment of the
ankle, hindfoot, midfoot, and forefoot joints should be performed
with special attention to any limitations of motion that may call
attention to injury of each respective joint or associated muscle
group. Localization of pathology is facilitated through palpation
of the easily appreciated bony and tendonous structures of the
foot and ankle. Thorough neurovascular examination is essential.
The practitioner must resist the temptation to rely solely
on history and physical examination even when the diagnosis
seems obvious. Quality weight-bearing radiographs in the
anteroposterior (AP), lateral, and mortise planes are standard for
evaluation of the ankle. Radiographic examination of the foot
should consist of AP, lateral, and oblique projections. When
thorough history, examination, and standard radiographs fail to
yield a diagnosis, specialized radiographic views may be helpful.
Stress views, magnetic resonance imaging (MRI), computed
tomography (CT), and radionuclide studies are all powerful tools
when applied in the appropriate setting.
OVERVIEW OF WORKPLACE INJURIES
Ankle
Five percent of all work-related injuries requiring time away
from work in 2003 involved in the ankle.
25
This section presents
an overview of workplace ankle injuries divided into two major
subsections, the first devoted to fractures and the second to
sprains. Of course, injuries to the ankle are seldom this black and
white. Included in the section on ankle fractures is a section on
tibial pilon fractures. Although not ankle fractures per se, tibial
pilon fractures involve and profoundly affect the ankle and are
therefore included. The section on ankle sprain includes a dis-
cussion of fractures and other pathology that may present simi-
lar to ankle sprains, so that the reader may keep these injuries in
mind when evaluating a seemingly straightforward ankle sprain.
Fractures about the ankle
Tibial pilon fractures Fractures involving the distal weight-
bearing articular portion of the tibia are termed tibial pilon
fractures. These fractures represent high-energy injuries and occur
most commonly after a fall or motor vehicle crash. Not only are
these fractures frequently comminuted, but they represent severe
soft tissue injury to the ankle as well. These injuries are seldom
amenable to closed treatment and often require immediate
external fixation and delayed open reduction and internal
fixation (ORIF). Complications after treatment are common and
include full thickness skin loss, infection, and posttraumatic
arthritis. McFerran et al
13
reported a major complication rate of
42% after operative treatment of severe tibial pilon fractures.
Long-term impairment is common and is usually due to pain
and stiffness secondary to posttraumatic arthritis.
Ankle fractures Ankle fractures are typically the result of
sudden twisting, inversion, or eversion of the ankle. Immediate
onset of pain and swelling usually ensues. Depending on the sever-
ity of the injury, weight bearing may be impossible. Examination
reveals swelling, tenderness, and ecchymosis about the ankle.
These injuries vary considerably with respect to severity, treat-
ment, convalescence, and potential for long-term impairment.
Isolated fractures of the distal fibula are the most common
ankle fractures. Unless open or widely displaced, these relatively
low-energy injuries are amenable to closed treatment. Closed
treatment requires four to six weeks of nonweight bearing in
a short leg cast followed by an additional four to six weeks of
weight bearing in a removable cast. Once weight bearing is begun,
physical therapy is initiated, focusing on strengthening, range of
motion, and edema reduction. Work-specific therapy may begin
in a soft or lace-up ankle brace once resisted ankle eversion
strength cannot be overcome by the examiners hand (Fig. 8c.1).
Chapter 8c Foot and ankle disorders in the workplace 352
Figure 8c.1 Examination of ankle evertor strength. The patient is
asked to evert the ankle against resistance.
At this point, part-time light duty work may begin. Return to
unrestricted duty may take three to four months after injury.
Maximum medical improvement is typically reached within six
months of injury.
Isolated fractures of the medial malleolus are less common.
Unlike isolated fractures of the lateral malleolus, these injuries
are typically displaced and relatively unstable. When combined
with a fracture of the proximal fibula, this injury represents a
highly unstable injury pattern with rupture of the syndesmotic
membrane (Massoneuve fracture). Nonetheless, if nondisplaced
and stable, they may be treated closed using a similar protocol
as outlined for isolated fractures of the lateral malleolus. More
commonly, these injuries require ORIF. After ORIF, a six to
twelve week period of short leg casting with nonweight-bearing
restriction is instituted until healing has occurred as determined
by lack of tenderness and bridging bone on radiographs. A six
week course of protected weight bearing is combined with
physical therapy focusing on strengthening, range of motion,
and edema reduction. Work-specific therapy may begin in a
soft or lace-up ankle brace once resisted ankle eversion strength
cannot be overcome by the examiners hand. At this point, part-
time light duty work may begin. Return to unrestricted duty may
take six months or more after injury. Maximum medical
improvement may not be achieved for nine to twelve months
after injury.
Often, medial and lateral malleolar fractures occur in combi-
nation, creating an unstable bimalleolar ankle fracture. Fracture
of the posterior articular surface of the distal tibia in association
with lateral, medial, or bimalleolar fracture is not uncommon
as well. Bimalleolar and trimalleolar ankle fractures are almost
always unstable and may even be open. Immediate closed
reduction is performed under conscious sedation followed by
emergent ORIF for open fractures or ORIF within the first few
days of injury for closed fractures. Syndesmotic fixation may
be required if the distal fibula fracture occurs more than 3.5 cm
above the level of the ankle joint. The temptation to rely on
internal fixation alone for fracture stability is dangerous. Short
leg casting and nonweight-bearing restriction for eight to twelve
weeks is required while the fractures heal. Syndesmotic screws
are removed before the institution of weight bearing at approx-
imately eight weeks after surgery. Although the rehabilitation
phase is similar to that after ORIF of isolated malleolar fractures,
prolonged pain and stiffness is common. Engelberg et al
8
noted
residual physical effects, including pain and stiffness, for up to
20 months after injury.
Unfortunately, posttraumatic arthritis occurs in as many
as 14% of ankle fractures, often beginning within two years of
the injury.
12
Persistent symptoms of pain, stiffness, and swelling
beyond the typical course should prompt suspicion that post-
traumatic arthritis is imminent. Examination usually demonstrates
persistent ankle swelling, tenderness, and decreased range of
motion. Weight-bearing radiographs may show joint space
narrowing, osteophyte formation, and subchondral collapse.
Bracing in an ankle foot orthosis, oral antiinflammatory medica-
tions, and a single intraarticular corticosteroid injection may be
beneficial. Ultimately, surgical intervention may be required.
Although ankle arthroscopy has a limited role, it may be helpful
in osteophyte excision. Ankle arthrodesis is often required.
Workers who do progress to posttraumatic arthritis may be
unable to return to physically demanding occupations especially
after ankle fusion.
Ankle sprain
Acute inversion injury of the ankle may occur with minimal
energy such as when handling heavy objects on an uneven sur-
face such as a ramp or when stepping on an unexpected object
on the floor. Higher energy ankle sprains may occur when the
worker unloads from a higher level such as a truck cab or bed
onto an uneven or unstable surface. Regardless of the mecha-
nism, disruption of one or more of the lateral ankle ligaments
occurs, resulting in pain and often impressive swelling over the
anterolateral aspect of the ankle. Weight bearing is often but not
always limited secondary to pain.
Grading of ankle sprain is clinical with an anatomic basis.
The clinical hallmark of grade I ankle sprain is isolated tender-
ness over the anterolateral aspect of the ankle. Range of motion
of the ankle and hindfoot is usually limited by pain and swelling.
The patient is typically able to bear weight, although with dis-
comfort. This injury represents a partial tear of the anterior
talofibular ligament. Grade II ankle sprain is suggested by pain
prohibitive of weight bearing after the acute inversion injury.
Tenderness is still localized to the anterolateral ankle. Complete
disruption of the anterior talofibular ligament is likely to
have occurred at this stage. Finally, disruption of both the ante-
rior talofibular ligament and calcaneofibular ligament occurs in
grade III sprain. Examination reveals tenderness both laterally
and medially along the deltoid ligament and is often accom-
panied by massive swelling. Radiographs of both the ankle and
foot should be obtained to rule out fracture.
Treatment is the same initially for all grades of sprain.
Immobilization, either in an ankle stirrup splint or a removable
fracture boot, is combined with ice, compression, and elevation.
This is conveniently summarized in the pneumonic RICE: rest,
ice, compression, and elevation. Although pain is often prohibi-
tive of weight bearing, ambulation may be encouraged in a
removable fracture boot with the aid of crutches. Physical ther-
apy should be initiated as soon as possible. Initial modalities
should be aimed at edema reduction including elevation, inflat-
able foot pump, and active range of motion in a whirlpool.
Within one week of injury, strengthening exercises of the per-
oneal muscles and proprioceptive training are initiated. Once the
patient demonstrates return of peroneal function such that ankle
eversion strength cannot be overcome by the examiners hand,
they are graduated to a lace-up ankle brace with Velcro inversion-
resistant straps such as an ASO brace (Medical Specialties, Inc.,
Charlotte, NC, USA). Discontinuation of immobilization and
physical therapy before this endpoint is reached predisposes the
patient to risk of recurrent sprain and chronic ankle instability.
Anticipated return to work depends on the grade of injury.
Generally, patients with all grades of ankle sprain may be returned
to work at the sedentary level within one to two weeks of injury.
Advancement to full duty should be withheld until peroneal
muscle strength, swelling, and range of motion are within 90%
of the opposite side. This may take as little as four weeks for
grade I sprains and as long as eight weeks for grade III sprains.
Persistently painful ankle sprain Unfortunately, as many
as 20% to 40% of patients who sustain a grade III ankle sprain
Chapter 8c Overview of workplace injuries 353
experience continued pain and stiffness beyond eight weeks postin-
jury. Although this is most often due to inadequate rehabilitation,
other etiologies must be considered, including ankle instability,
tears or tendonitis of the peroneal tendons, impingement lesions,
osteochondral lesions of the talus, and occult fractures.
Ankle instability Instability of the ankle is not uncommon after
ankle sprain. Ankle instability may be functional or mechanical;
in both types the patient may complain of sudden giving way
of the ankle as it rolls into inversion on uneven or unstable
surfaces. Mechanical instability, unlike functional instability,
may be readily demonstrated by examination by a positive ante-
rior drawer test and confirmed by positive stress radiographs
(Figs. 8c.2 and 8c.3). Regardless of the type of ankle instability,
the response is usually favorable to aggressive physical therapy
emphasizing peroneal muscle strengthening and proprioceptive
training. If symptoms and findings persist, surgical reconstruc-
tion of the lateral ankle ligaments may be indicated. Return
to full duty at the heavy demand capacity may require 12 to
16 weeks, until which the worker may benefit from continued
proprioceptive training and peroneal strengthening.
Tear of peroneus longus or brevis tendon The peroneus longus
and brevis tendons are important dynamic stabilizers of the
ankle. Originating from the fibula and interosseous membrane,
the peroneus longus and brevis muscles give rise to their respective
tendons above the ankle joint. Sitting anterior to the longus at
the level of the ankle joint, the peroneus brevis is cup shaped in
cross-section and cradles the peroneus longus tendon posteriorly
as they are redirected anteriorly around the tip of the distal
fibula. Both tendons are held firmly in a groove in the posterior
fibula distally by the superior and inferior peroneal retinaculum.
At this level the peroneal tendons are susceptible to either tear-
ing or subluxation out of the fibular groove with failure of the
peroneal retinaculum. The exact incidence of peroneal tendon
tears or subluxation with ankle sprain is speculative.
20
Most tears
are longitudinal and probably heal with treatment of the sprain.
A tear of one or more of the peroneal tendons should be
suspected if lateral ankle pain persists beyond the expected course
of improvement for ankle sprains. Typically, these patients
demonstrate a varus heel and high arch. Tenderness is often greatest
along the course of these tendons, particularly posterior to the
tip of the distal fibula when the peroneus brevis is involved and in
the soft spot just proximal to the base of the fifth metatarsal
about the plantar lateral midfoot when the peroneus longus is
involved.
18
MRI examination usually confirms the diagnosis.
These patients often have residual instability of the ankle and
deserve an additional six week course of physical therapy devoted
to strengthening of the peroneus brevis and longus tendons.
Surgical repair is indicated if conservative treatment fails.
Simultaneous surgical treatment of ankle instability may be nec-
essary if stress radiographs are positive. The return to work pro-
tocol is similar to that after lateral ankle ligament reconstruction.
Subluxation or dislocation of the peroneal tendons may be
diagnosed acutely. The examiner has the patient dorsiflex the
ankle against resistance and a palpable pop may be elicited over
the peroneal tendons (Fig. 8c.4). Overt dislocation may be seen
as an abnormal prominence of these tendons coursing over rather
than behind the lateral malleolus (Fig. 8c.5). A six week course
of casting the ankle in the inverted position with a felt pad
posterior to the lateral malleolus is often successful if the con-
dition is discovered and treated early. Delayed presentation
Figure 8c.2 Lateral radiograph of the ankle showing abnormal
anterior translation of talus with anteriorly applied stress.
Figure 8c.3 Anteroposterior radiograph of the ankle showing
abnormal varus angulation of the talus with medialward stress.
of this problem often requires surgical reconstruction of the
peroneal retinaculum and deepening of the peroneal groove.
Impingement lesion Persistent anterolateral ankle pain in the
absence of specific findings on examination and MRI should
prompt suspicion of an anterolateral ankle impingement lesion.
Due to single or repeated ankle sprains, hypertrophy of the anterior
tibiofibular or talofibular ligament may occur, resulting in a painful
pinching sensation over the front of the ankle with dorsiflexion
as this tissue subluxes into and out of the ankle joint. Diagnosis
may be confirmed if pain resolves with sterile saline injection
into the ankle joint. This syndrome commonly resolves with rest
as edema around the ankle subsides. Nonetheless, persistence of
this problem may result in the need for arthroscopic debridement.
Osteochondral lesion of the talus Injury to the cartilage and
subchondral bone of the talus occurs in as many as 6.7% of
ankle sprains.
1
That said, not all osteochondral lesions of the
talus are due to trauma. Canale and Kelly
3
noted that only
67% of medial talar dome lesions are associated with injury.
Tenderness is usually nonspecific but may be greatest over the
dome of the talus when the ankle is hyperplantarflexed. These
lesions may be staged by radiographic appearance using the
Berndt and Harty classification (Table 8c.1).
1
Stage I or II lesions
usually respond to an initial period of nonweight bearing with
cast immobilization, followed by progressive weight bearing and
mobilization to full weight bearing within 12 to 16 weeks. Failure
of nonsurgical treatment or advanced stage III or IV lesions may
require surgical management.
Occult fracture Fractures of the anterior process of the calca-
neus and injuries to the posterior process of the talus may be
overlooked on initial examination and radiographs after inver-
sion injury to the ankle. Fracture of the anterior process of
Figure 8c.4 The examiner has the patient dorsiflex the ankle against
resistance and a palpable pop may be elicited over the peroneal
tendons (arrow).
Figure 8c.5 Overt dislocation may be seen as an abnormal
prominence of the peroneal tendons coursing over rather than behind
the lateral malleolus (arrow).
Table 8c.1 Berndt and Harty classification of osteochondral lesions of the talus, radiographic appearance,
and recommended treatment options
Berndt and Harty stage Radiographic appearance Treatment options
I Subchondral bone compression Nonweight bearing in short leg cast for 6 weeks
Surgery reserved for persistent symptoms
II Partially detached osteochondral fragment Nonweight bearing in short leg cast for 6 weeks
Surgery reserved for persistent symptoms
III Completely detached nondisplaced osteochondral Surgical treatment: either excision, drilling, and curettage or internal
fragment fixation
Osteochondral autografting
IV Displaced osteochondral fragment (loose body) Surgical treatment: either excision, drilling, and curettage or internal
fixation
Osteochondral autografting
the calcaneus may be detected with plain radiographs (Fig. 8c.6)
or CT (Fig. 8c.7). If detected acutely, anterior process of the
calcaneus fractures are best treated nonweight bearing in a
removable cast, with institution of range-of-motion and strength-
ening exercises beginning 5 to 7 days after injury. ORIF may
be required for large displaced fractures propagating through
the calcaneocuboid or subtalar joints. Delayed presentation is
common and is best treated with excision of the fragment with
or without subtalar or talonavicular arthrodesis. These fractures
may require 2 to 3 months for healing, at which point physical
therapy may begin.
Paulos et al
15
noted that 17 of 20 posterior processes of
the talus fractures (Shepherds fractures) after inversion injuries
were missed. Confusion arises from the frequent presence of an
accessory ossicle originating from the posterior process of the
talus (os trigonum). Fracture may occur either through the syn-
chondrosis between the os trigonum and posterior talus or
through the posterior process itself. Examination reveals pos-
terior ankle pain on forced plantarflexion of the ankle. CT,
technetium bone scan, or MRI are helpful when confusion
regarding diagnosis exists. Acute injuries are treated in a short
leg walking cast for 4 to 6 weeks until fracture union occurs or
symptoms resolve. If pain persists or if these injuries are discov-
ered late, excision after diagnostic injection is recommended.
FOOT
Almost 5% of all work-related injuries requiring time away from
work in 2003 involved in the foot or toes.
25
Like the section on
ankle injuries, this section is divided into sections on fractures
and on sprains and dislocations. Three sections are also included
relating to nerve injuries, chronic regional pain syndrome, and
crush injuries. The reader must keep in mind that although these
topics are all individualized to facilitate discussion, they seldom
occur in isolation. For instance, sprains or dislocation of the
tarsometatarsal (TMT) joints are usually accompanied by frac-
tures of one or more metatarsal or tarsal bones, and these injuries
must be considered together. Nerve injuries are discussed
individually but commonly coexist with significant disruptions
to the major bony or ligamentous structures of the foot. This
section clarifies these relationships whenever possible.
Fractures of the foot
This section provides an overview of work-related fractures of
the foot, including fractures of the calcaneus, talus, midtarsal
bones of the midfoot, metatarsals, sesamoids, and the phalanges
of the toes.
Calcaneus fracture In 1916, Cotton
4
commented, the man
who breaks his heelbone is done. Fortunately, advances in
operative technique and improved understanding of operative
indications have since improved this outlook. Nonetheless,
these remain one of the most challenging injuries to treat in the
workers compensation population.
Calcaneus fractures are almost always the result of a high-
energy crushing mechanism such as a fall from a height or motor
vehicle crash. Ipsilateral fractures of the medial malleolus, tibial
plateau, or lumbar spine are commonplace. These patients must
Figure 8c.6 Lateral radiograph showing anterior process of the
calcaneus fracture.
Figure 8c.7 Computed tomography confirming anterior process of the
calcaneus fracture.
be approached as any potential multisystem trauma using standard
trauma protocols; injuries to the head, chest, abdomen, spine,
and pelvis take obvious precedence.
Once more significant injuries have been ruled out, evalua-
tion of the potential calcaneus fracture is performed. The patient
usually complains of heel pain. Shortening and widening of
the hindfoot may be seen. Tenderness, swelling, and ecchymosis
are typical. Standard radiographic assessment of the ankle and
foot should be performed. Lateral radiograph of the heel is use-
ful to quantify the degree of calcaneal shortening by meas-
urement of Bhlers angle (Fig. 8c.8). Produced by the acute
intersection of a line drawn parallel to the posterior tuberosity
and another connecting the highest point on the anterior process
to that of the posterior facet, a Bhler angle normally measures
20 to 40 degrees. Intraarticular step-off of the posterior facet may
be visualized using Brodns view (Figs. 8c.9 and 8c.10). Axial
projection is helpful to demonstrate widening and the degree
of varus malalignment of the posterior tuberosity. Although radi-
ographs are essential, the CT has become a vital assessment tool
in evaluation of the calcaneus fracture. Semicoronal cuts through
the posterior facet of the subtalar joint are obtained to ascertain
the number of intraarticular fracture lines, the degree of intraar-
ticular step-off, and the magnitude of varus malalignment.
Immediate treatment is aimed at reducing the impact of
soft tissue injury. Ideally, a Jones cotton compressive dressing
and a posterior splint are applied. Admission to the hospital is
recommended for ice, elevation, and observation for compart-
ment syndrome. Compartment syndrome of the foot should
always be suspected prompting low threshold for manometry
and subsequent fasciotomies. Over the ensuing days, massive
soft tissue swelling often develops with subsequent fracture
blisters. Sterile decompression of nonhemorrhagic fracture blis-
ters followed by application of nonadherent dressing should be
Figure 8c.8 Radiograph showing the tuber angle of Bhler (From
Borrelli J Jr, Torzilli PA, Grigene R, Helfet DL: Effect of impact load on
articular cartilage: development of an intraarticular fracture model.
J Orthop Trauma 11(5):319-326, 1997, and from Sanders R: J Bone
Joint Surg Am 82(2):225-250, 2000.)
X
-
R
A
Y
Figure 8c.9 Schematic drawings showing the technique for making
Brodns views. With the patient supine, the x-ray cassette is placed
under the leg and the ankle. The foot is in neutral flexion, with the leg
internally rotated 30 to 40 degrees. (From Burdeaux BD Jr: Reduction
of calcaneal fractures by the McReynolds medial approach technique
and its experimental basis. Clin Orthop (177):87-103, 1983.)
Figure 8c.10 The x-ray beam is centered over the lateral malleolus
and four radiographs are made, with the tube angled 40, 30, 20, and
10 degrees toward the head of the patient. (From Sanders R: J Bone
Joint Surg Am 82(2):225-250, 2000.)
performed within the first week of injury. Definitive treatment
depends on the integrity of the overlying soft tissues, presence of
comorbid conditions, and classification of the fracture.
Numerous classification systems for calcaneus fractures
exist. Sanders et al
23
devised a useful classification based on CT
(Fig. 8c.11). This system is based on the number and position of
displaced intraarticular fracture lines propagating into the widest
segment of the posterior facet of the subtalar joint as seen on
coronal CTs
Type I fractures are defined by the absence of displacement

regardless of the number of fracture lines.
Type II represent displaced fractures defined by a single

intraarticular fracture line.
Type III fractures are displaced fractures defined by two

intraarticular fracture lines.
Type IV represent displaced fractures defined by three or more

intraarticular fracture lines.
Each type is further divided into subtypes based on the
location of the fracture lines. Classification of calcaneus fractures
has become a vital tool in determining both the treatment and
prognosis of these injuries.
Closed treatment is indicated for Sanders type I fractures or
when poor quality soft tissues prevent safe surgical incisions.
Tobacco dependence, diabetes, and vascular disease may dictate
closed treatment as well due to inordinately high potential for
wound complications postoperatively.
21
Early mobilization is
preferable to prolonged immobilization. The patient is placed
in a removable CAM walker boot and begins range-of-motion
exercises of the ankle and foot within two weeks of the injury.
Partial weight bearing may commence within six weeks of injury.
The patient may be advanced to weight bear as tolerated, and
within 12 weeks the boot may be discontinued altogether.
The worker may then resume regular shoe wear, although a larger
size may initially be required to accommodate heel widening.
Figure 8c.11 Classification of intraarticular
calcaneal fractures according to Sanders et al:
type I, nondisplaced fractures; type II,
displaced fractures; and type III, comminuted
fractures. (From Sanders R: J Orthop Trauma
6:254, 1992, and From Sanders R: J Bone
Joint Surg Am 82(2):225-250, 2000.)
A full-length custom-molded or over-the-counter heel insert may
provide additional comfort. A return to unrestricted duty may
take up to six months.
Surgical treatment is indicated for all open fractures. Sanders
type II, III, and IV fractures generally benefit from surgical
treatment; however, surgery is best deferred for 7 to 14 days
until swelling has improved as indicated by circumferential skin
wrinkling. Surgery through skin blisters should be avoided.
Although ORIF is preferable whenever possible, primary subta-
lar arthrodesis may be indicated when two or more displaced
intraarticular fracture lines extend into the subtalar joint, as in
Sanders type IV fractures. Coughlin,
5
Sanders,
22
and others
recommended a lower threshold for primary arthrodesis in work-
related calcaneus fractures. Coughlin
5
demonstrated that return
to work was delayed from an average of 6 months to 18 months,
and treatment cost nearly doubled when ORIF failed and
delayed subtalar arthrodesis was required.
Unfortunately, 10% to 20% of patients who undergo ORIF
of calcaneus fractures sustain postoperative complications such
as delayed wound healing, infection, or sural neuritis.
24
Wound
complications may be twice as likely in tobacco users, and
smoking cessation should be included in the treatment plan.
As with all periarticular lower extremity fractures, posttraumatic
arthritis is common. Coughlin
5
reported that 7 of 16 intraar-
ticular calcaneus fractures that underwent initial ORIF later
required subtalar arthrodesis. Anterior impingement of the
ankle; peroneal tendon subluxation, dislocation, or tendonitis;
and chronic heel pain are all potential long-term sequelae of
calcaneus fractures.
After surgical treatment, the limb is immobilized in a fracture
brace or short leg cast. Strict elevation is maintained for the
initial four weeks after surgery to minimize edema and poten-
tial wound complications. After four weeks, physical therapy is
begun at a frequency of three visits weekly. Range-of-motion,
edema control, and strengthening exercises are performed. Partial
weight bearing begins six weeks after surgery, and full weight bear-
ing is usually delayed until 12 weeks after surgery. Immobilization
and nonweight-bearing restriction is extended to at least eight
weeks postoperatively after primary arthrodesis.
Most patients may return to part-time sedentary work while
maintaining strict elevation of the foot between four and six
weeks after surgery. Progression to part-time light duty with
hourly elevation breaks lasting 15 minutes may begin 12 weeks
after surgery. Progress is usually gradual, and it may take four
to six months before a full eight hour light duty shift is tolera-
ble. A return to full duty may take a year or more. Chronic
swelling and pain may limit tolerance to standing and walking.
Uneven surfaces such as those encountered in the roofing and
construction trades may be intolerable. Pain and stiffness may
preclude occupations requiring ladder climbing and balancing
on scaffolding. Unfortunately, workers within these professions
are disproportionately represented among those who sustain
calcaneus fractures. Work hardening and functional capacity
evaluation are helpful to establish long-term work restrictions.
Talus fractures Fractures of the talus are divided into those of
the neck, body, and posterior or lateral processes. Fractures of
the neck of the talus are typically caused by dorsiflexion of the
ankle beyond the physiologic range of motion, such as when the
brake pedal foot is forced dorsally with the direct impact of a
motor vehicle crash. The anterior aspect of the distal tibia acts
as a wedge, splitting the talus at the neck. Fractures of the talar
body occur from axial loading such as those seen in falls from
a height. Lateral process fractures are avulsion injuries of the
origin of the lateral talofibular ligament and generally occur
with inversion injury. Posterior process fractures result from
hyperplantarflexion and impingement between the posterior
aspect of the tibia and the calcaneus.
The injured worker with a talus fracture complains of pain
about the ankle joint. Swelling, tenderness, and ecchymosis are
usually present. Forced plantar flexion of the ankle reproduces
pain when posterior process fractures are present. High-energy
talar neck or body fractures may present with skin tenting or even
extrusion of the talar body. Open injuries are commonplace.
Coexisting injuries are common and must be ruled out using
standard trauma protocols.
Radiographic examination consists of AP, mortise, and lateral
views of the ankle. Lateral, AP, and oblique views of the foot
must be obtained. A talar neck view is helpful and is obtained by
elevating the lateral border of the foot 15 degrees off the plantar
placed x-ray cassette and canting the x-ray gantry 15 degrees away
from the ankle toward the forefoot (Fig. 8c.12). CT has become
the standard for evaluating talus fractures and may reveal frac-
tures or comminution not appreciated on standard radiographs.
Nondisplaced fractures of the neck or body of the talus may
be treated closed. As soon as swelling permits, a short leg cast
is applied. Nonweight-bearing restriction is enforced for six
to eight weeks until healing occurs. Displaced talar neck or body
fractures may be accompanied by dislocation of the ankle or
subtalar joint and should undergo urgent reduction followed by
Figure 8c.12 Radiographic positioning for the oblique view of the
talar neck, as described by Canale and Kelly.
3
(From Fortin PT, Balazsy JE:
Talus fractures: evaluation and treatment. J Am Acad Orthop Surg
9(2):114-127, 2001.)
ORIF as soon as soft tissues permit. Open injuries require emer-
gent irrigation, debridement, and stabilization. Immobilization
in a short leg cast may be required for up to four months. After four
months, the weight-bearing status is advanced to allow weight
bearing as tolerated in a fracture boot. After cast removal, range-
of-motion and strengthening exercises as well as edema reduction
techniques are performed three times weekly in physical therapy.
Fractures of the posterior process are often difficult to distin-
guish from injury to the os trigonum. Fortunately, treatment is
similar. If symptoms persist beyond a six week course of casting,
excision of the symptomatic os trigonum or posterior process
fragment after positive diagnostic injection is recommended.
Nondisplaced fractures of the lateral process are under-diagnosed.
If discovered, late excision may be required; otherwise they may
be treated with a six week course of short leg casting with a
nonweight-bearing restriction. Large displaced fragments may
require ORIF, whereas comminuted fractures may benefit from
excision.
Long-term complications of talus fractures are common and
include posttraumatic arthritis and avascular necrosis. Elgafy
et al
7
reported high rates of posttraumatic arthritis of the subta-
lar joint (53%) and ankle joints (25%) after fracture of the talus
in a series of 60 talus fractures. Failure of conservative treatment
may necessitate subtalar or ankle arthrodesis. Reported rates
of avascular necrosis vary but may approach 100% of severely
displaced fractures. Subchondral lucency of the dome of the
talus on AP radiographs of the ankle occurring between six and
ten weeks after fracture (Hawkins sign) is considered diagnostic
of viability of the talar dome.
10
Limitation of weight bearing
using a patellar tendon bearing ankle foot orthosis may be
required for up to a year while the talus revascularizes.
Workers with conservatively treated fractures of the talus may
return to sedentary duty within two to three weeks of injury.
After surgical management, the requirement for strict elevation
precludes return to sedentary work until four weeks postop-
eratively. Once full weight bearing is achieved, part-time light
duty with frequent rest breaks may be initiated. Patients with
conservatively treated talus fractures may be returned to full duty
three to four months after injury, whereas those with displaced
fractures treated surgically may require 6 to 12 months depend-
ing on the presence of avascular necrosis (AVN) or osteoarthritis.
Work hardening, functional capacity evaluation, and even occu-
pational change may be required.
Tarsal bones of the midfoot fractures The midtarsal bones
are important in maintaining the geometry of the foot. They
may be thought of as constructing two columns, medial and
lateral. The medial column consists of the navicular proximally
and the three cuneiforms distally. The cuboid constitutes the
lateral column. The analogy to columns is important, because
fractures of tarsal bones within either column tend to result in
loss of pedal length either medially or laterally with profound
effects on the shape and function of the foot. Crush fractures
of the cuboid may result in lateral column shortening, midfoot
abduction, and pes planus. Pes cavus may occur with shortening
of the medial column, usually secondary to navicular fractures.
Furthermore, fractures of the midfoot bones are usually intraar-
ticular, and these injuries may result in posttraumatic arthritis.
Often, midtarsal fractures are but one component of high-energy
crush injuries with coexisting skin compromise, nerve injury, or
compartment syndrome. Once the soft tissues are stabilized,
treatment of these injuries should focus on maintaining column
geometry and articular congruity. Posttraumatic arthritis is
common after these fractures, and highly comminuted fractures
may require primary intertarsal arthrodesis. Return to work varies
widely depending on the severity of the injury. Isolated nondis-
placed fractures treated closed may be returned to sedentary
duty almost immediately. A patient with injuries requiring ORIF
or primary arthrodesis may expect a delay in returning to full
unrestricted duty of three to six months.
Metatarsal fractures Metatarsal fractures may occur through
either or both the base or shaft of the metatarsals. When one
or more metatarsal base fractures are accompanied by midfoot
tenderness, the diagnosis of TMT fracture dislocation must
be entertained. TMT fracture dislocations are unstable injuries
that often require operative stabilization; these are covered in
the section pertaining to these injuries.
On the contrary, isolated metatarsal fractures generally respond
well to conservative treatment. The injured limb is initially
elevated in a soft compressive dressing to control swelling. This
is then changed to a hard-soled shoe or removable fracture boot
for four to six weeks. Weight bearing to pain tolerance is per-
mitted during this time. Sedentary work may be permitted
until radiographic healing has occurred. Once healing is evident
radiographically, the patient may begin part-time light duty.
During this time, physical therapy is performed, aimed at edema
reduction and strengthening. Residual forefoot pain is best
treated with a semirigid custom foot orthotic. A return to heavy
duty is usually possible within 8 to 12 weeks of injury.
Certain metatarsal fractures require special attention. Displaced
fractures of the first metatarsal require anatomic reduction.
If anatomic reduction cannot be maintained, then operative
stabilization may be required. Fractures of the proximal fifth
metatarsal metadiaphyseal junction (Jones fracture) are important
to recognize because these have a significant rate of nonunion
(Figs. 8c.13 and 8c.14). These injuries are best treated with
nonweight-bearing cast immobilization for 6 to 8 weeks. The
rate of successful union with this treatment has been reported to
be between 72% and 93%.
17
Sesamoid fractures Fracture of the medial or lateral sesamoid
bones of the foot may occur either acutely or in response to
stress. Acute injuries are usually the result of sudden hyperdor-
siflexion injury to the hallux MTP joint. This may result in
transverse fracture more commonly of the medial sesamoid
(Fig. 8c.15). Stress injuries are most common in athletes and
dancers and usually demonstrate a stellate fracture pattern. Point
tenderness is usually found directly beneath the involved sesamoid.
Radiographic studies should include basic AP, lateral, and oblique
projections of the foot. Specialized axial and oblique sesamoid
views may also be helpful (Figs. 8c.16 and 8c.17). Radiographic
studies may be somewhat confusing due to the high incidence of
bipartite sesamoids (5-30%). MRI or technetium-labeled red
blood cell radionuclide study may be useful when radiographs
are nondiagnostic.
Acute fractures deserve a six week course of nonweight-
bearing restriction in a short leg cast. The worker may then
return to part-time light duty in a semirigid foot orthosis with
relief under the affected sesamoid and a metatarsal bar. Although
unrestricted duty may generally be resumed within three
months, kneeling may prove especially difficult as it requires
maximum dorsiflexion of the hallux MTP joint. Work hardening
and physical therapy should focus specifically on the restoration
of painless dorsiflexion of the great toe.
Phalangeal fractures Fractures of the toe phalanges are the
most common osseous injury to the foot in the general popula-
tion.
6
Phalangeal fractures are best treated with closed reduction
Figure 8c.13 Anteroposterior radiograph of a typical acute Jones
fracture (arrow). The fracture line is intraarticular and involves the
fourth-fifth intermetatarsal articular facet. (From Rosenberg GA,
Sferra JJ: J Am Acad Orthop Surg 8(5):332-338, 2000.)
Figure 8c.14 Lateral radiograph of a typical acute Jones fracture
(arrow). The fracture line is intraarticular and involves the fourth-fifth
intermetatarsal articular facet. (From Rosenberg GA, Sferra JJ:
J Am Acad Orthop Surg 8(5):332-338, 2000.)
Figure 8c.15 Intraoperative photo showing medial sesamoid fracture.
Figure 8c.16 Sesamoid oblique view showing fracture of the medial
sesamoid.
Figure 8c.17 Sesamoid axial view showing lateral (A) and medial
(B) sesamoids.
under digital block anesthesia, followed by buddy taping to
the adjacent medial toe. A hard-soled shoe is worn until cessa-
tion of pain, tenderness, and swelling herald fracture healing,
usually within four weeks. The worker is then returned to regular
duty with preventative measures such as steel-toed shoes in place.
Unstable closed reductions that manifest as obvious toe defor-
mity require percutaneous pinning. These patients need to remain
nonweight bearing on the affected extremity until the pin is
removed, usually around six weeks after injury. Displaced intraar-
ticular fractures of the hallucal proximal phalanx may benefit
from ORIF with a return to light duty between six and ten weeks
after injury.
Persistent swelling or pain should always be taken seriously,
because it may belie fracture nonunion. This may be addressed with
operative fixation and grafting. Residual disability is uncommon.
Sprains and dislocations
Ligament injuries may occur about any joint in the foot, but
most commonly occur about the TMT and the hallux MTP
joints. Strong ligamentous attachments and highly congruent
articulations, particularly about the TMT joint, may result in
coexisting fractures when these joints are injured.
TMT joint injuries The TMT joint, also known as Lisfrancs
joint, is the stable articulation between the five metatarsal bases
and the midtarsal bones (medial, middle and lateral cuneiforms,
and the cuboid). The most important of these articulations is
the second TMT joint. The second TMT joint is a stable mortise
created proximally by the geometry of the three cuneiform
bones. These bones create a three-sided notch into which sits
the base of the second metatarsal (Fig. 8c.18). The second
metatarsal is the only metatarsal to articulate with three tarsal
bones and is anchored in its mortise by Lisfrancs ligament.
Lisfrancs ligament originates from the plantar aspect of the medial
cuneiform and extends to the base of the second metatarsal.
Injury to this ligament has a destabilizing effect on the midfoot
that may lead to deformity, dysfunction, and pain if not recog-
nized and treated.
Although motor vehicle crashes are the most common cause
of injury to the TMT joint, these injuries are also frequently seen
in the industrial setting. They may occur as a result of direct
trauma such as a crush as seen in a forklift injury or as the result
of a sudden twisting and axial loading of the plantar flexed foot.
The Napoleonic era surgeon Lisfranc provided insight into the
mechanism of injury by noting it to occur in cavalry with trau-
matic dismount from the stirrup.
The severity of these injuries varies considerably. Mild sprains
are characterized by mild midfoot tenderness and swelling.
Radiographic appearance is normal. Minor sprains may be treated
with rest, ice, and elevation followed by immobilization in a
removable fracture boot with early institution of weight bearing.
Sedentary work restriction is placed for four to six weeks or until
tenderness has resolved. Unfortunately, these injuries are often
underestimated in terms of severity or missed outright.
Moderate and severe sprains are usually characterized by
pain prohibitive of weight bearing. Examination reveals marked
swelling, tenderness, and ecchymosis about the midfoot.
Ecchymosis localized to the plantar aspect of the midfoot
beneath the first TMT joint may be seen (Fig. 8c.19).
Radiographic findings are often subtle, consisting of widening
between the base of the second metatarsal and medial
cuneiform. Widening of more than 2 mm compared with the
opposite side is considered diagnostic of unstable injury. A fleck
of bone may be seen in this interval on radiographs representing
avulsion of the origin of Lisfrancs ligament from the medial
cuneiform. Disruption of normal continuity between the medial
cortex of the second metatarsal base and middle cuneiform or
between the medial base of the fourth metatarsal and cuboid are
Figure 8c.18 (A) Anteroposterior view of the bony and ligamentous
anatomy of tarsometatarsal joint complex I through V = metatarsal
bones. (From Myerson MS: Fractures of the midfoot and forefoot. In
MS Myerson, ed: Foot and ankle disorders. Philadelphia, 2000, W.B.
Saunders, pp. 1265-1296.) (B) Coronal section through the metatarsal
bases illustrating the Roman arch configuration. (From Lenczner EM,
Waddell JP, Graham JD: Tarsal-metatarsal (Lisfranc) dislocation.
J Trauma 14(12):1012-1020, 1974, and from Thompson MC,
Mormino MA: Injury to the tarsometatarsal joint complex. J Am Acad
Orthop Surg 11(4):260-267, 2003.)
also diagnostic of unstable injury. Comparison views of the
opposite foot are helpful. Clinical signs and symptoms, even in
the setting of negative comparison radiographs, warrant CT of
the midfoot. Even when plain radiographs are normal, fractures
of one or more metatarsal bases or their corresponding tarsal
bones may be seen on CT belying an unstable injury to the TMT
joint complex. Fracture dislocation of one or more metatarsal
bases, the cuneiform, or cuboid bones is not uncommon. Soft
tissue injury may be marked, with skin tenting or even skin
penetration occurring. Compartment syndrome must always be
suspected. Tense edema of the foot, paresthesias in the toes, and
midfoot pain with flexion-extension of the toes are all support-
ive of the diagnosis of compartment syndrome. Threshold
should be low for manometric examination of the foot and
subsequent fasciotomies, as the sequelae of missed compartment
syndrome are unacceptable and may include disabling deformity
and neurologic injury.
Treatment of an unstable TMT joint injury requires surgical
stabilization. Minimally displaced injuries may be treated with
closed reduction and internal fixation, whereas more severe
and open injuries require ORIF. Transarticular fixation must be
removed before weight bearing is resumed, usually between three
and four months after surgery. Nonetheless, range-of-motion
and strengthening exercises may be instituted before hardware
removal, so that work hardening may begin shortly thereafter.
A custom semirigid foot orthosis is often beneficial. Although
light duty may begin five months after injury, it may be six to
nine months before a return to regular duty may occur.
Unfortunately, posttraumatic arthritis is common after unsta-
ble injuries, particularly when these injuries are missed. Persistent
midfoot pain, tenderness, and joint space narrowing are sugges-
tive of posttraumatic arthritis. When rigid foot orthosis and
oral and injected antiinflammatory medications fail, surgical
arthrodesis of the midfoot may be required. Calder et al
2
noted
a poor outcome in 13 of 46 patients with unstable work-related
TMT joint injuries. In this study, delay in diagnosis of more
than six months and the presence of a workers compensation
claim were associated with a poor outcome. Permanent change
in occupation is often necessary, and a functional capacity eval-
uation may be useful in establishing recommendations for future
employment.
MTP joint injuries Injuries to the MTP joint are most com-
mon about the great toe. Popularized in the sports medicine
literature as turf toe, hallux MTP joint injuries are not uncom-
mon in the industrial setting. Typically occurring with hyperdor-
siflexion of the hallux MTP joint, these injuries may result in
both compression injuries to the dorsal articular cartilage of
the first metatarsal head in addition to tensile damage to the
MTP joint capsule structures. Osteochondral defect of the first
metatarsal head; rupture of the plantar plate, collateral liga-
ments, or flexor hallucis brevis tendon; and bony injury to the
sesamoids are all within the spectrum of injury to the hallux
MTP joint.
Mild injuries represent stretch injuries to the plantar joint
capsule. Tenderness is isolated to the plantar and occasionally
the dorsal aspects of the hallux MTP joint. Radiographs are
typically negative. Acutely, rest, ice, and immobilization and
antiinflammatory medications are helpful. Taping of the great
toe should be instituted to limit extension of the MTP joint.
Weight bearing is allowed in a wooden-soled shoe until tender-
ness resolves.
Moderate to severe injuries represent complete disruption of
the plantar plate of the hallux MTP joint. Fracture of either medial
or lateral sesamoid or disassociation of the bipartite sesamoid
may be present. Osteochondral injury to the dorsal head of
the first metatarsal may coexist. Examination reveals tenderness,
swelling, and ecchymosis about the hallux MTP joint. Pain
occurs with any attempt at range of motion, and the hallux MTP
joint may be unstable with dorsal translation. Radiographs are
negative unless unreduced dislocation of the MTP joint, avul-
sion fracture of the base of the proximal phalanx, or sesamoid
fracture disassociation are present. Rest, ice, immobilization, and
antiinflammatory medications are helpful in the acute stage.
Irreducible dislocation may require open reduction. As with mild
injuries, protected weight bearing in a wooden-soled shoe and
taping are instituted.
Even with mild injuries, return to unrestricted or heavy
work may take as long as six months. Initially, sedentary work
may be initiated in a wooden-soled shoe. Once swelling and ten-
derness have resolved, the worker may return to light duty in a
standard shoe containing a low-profile rigid foot orthosis with a
Mortons forefoot extension (Fig.18c.20). Return to unrestricted
Figure 8c.19 Ecchymosis localized to the plantar aspect of the
midfoot beneath the first tarsometatarsal (TMT) joint as seen with TMT
joint fracture dislocation.
duty is delayed until full painless motion of the hallux MTP
joint has returned as compared with the opposite side.
Persistent pain after these injuries should not be dismissed.
If symptoms continue beyond three months, MRI examination
is warranted to detect either a stress fracture of the sesamoid or
an osteochondral injury to the first metatarsal head. Stiffness and
pain persisting six months beyond injury should prompt suspi-
cion of posttraumatic arthritis. Posttraumatic arthritis of the
hallux MTP joint, or hallux rigidus, is treated with antiinflamma-
tory medications and a rigid foot orthosis with a Mortons fore-
foot extension. Refractory pain may require surgical treatment.
Dorsal cheilectomy is indicated if the joint space is largely pre-
served; hallux MTP arthrodesis is reserved for end-stage arthritis.
Return to heavy labor is a reasonable goal after surgical man-
agement of hallux rigidus; however, a steel-toed shoe and a rigid
orthotic with a Morton forefoot extension are advised.
Injuries to the lesser MTP joints should not be discounted.
Hyperdorsiflexion injury may result in rupture of the plantar
plate with delayed claw toe deformity. Dorsal dislocation may
require open reduction if unreducible. Acutely, immobilization
in a Budin splint (Apex Foot Health Industries, Inc., Teaneck, NJ,
USA) and buddy taping is helpful. The patient may be graduated
to a full-length rigid insert with a metatarsal bar once swelling
and tenderness have resolved.
Nerve injuries
Peripheral nerve disorders are common sequelae of traumatic
events in the lower extremity. Painful and hypersensitive areas
of perineural scarring may occur either along a nerve (neuroma
in continuity) or at a site of nerve transaction (stump neuroma).
Adhesive neuralgia may affect a length of nerve in response to
either injury or surgery. Delayed diagnosis of compartment
syndrome may result in ischemic nerve damage. Given the lack
of objective findings and the often disabling symptomatology
associated with peripheral nerve lesions, these injuries represent
formidable diagnostic and treatment challenges in any setting.
Typical complaints that should alert the practitioner to under-
lying nerve injury include numbness, burning pain, or hyper-
sensitivity in the distribution of one or more sensory nerves of
the foot. Percussion along an injured nerve with the examiners
fingertip may reproduce descending paresthesias (Tinels sign).
Thorough neurologic examination may uncover underlying
radiculopathy or peripheral neuropathy predisposing to nerve
injury.
19
Peripheral nerve blocks are helpful in both localizing
pathology and determining potential response to treatment.
Electrodiagnostic studies should also be performed early to doc-
ument the location and degree of nerve injury and to uncover
contributing pathology such as radiculopathy or neuropathy.
Treatment of peripheral nerve injuries in the acute setting
involves direct surgical repair of transected essential motor nerves
including the tibial and common peroneal nerves. Although pri-
mary repair of sensory nerves such as the distal superficial and
deep peroneal nerves and the sural and saphenous nerves is con-
troversial, clean lacerations may benefit from epineural suturing.
Return of sensory function from the site of repair is gradual and
may be followed by descending percussion sensitivity that is
generally thought to proceed at 1 mm/day. Electrodiagnostic testing
is indicated three months after repair to confirm recovery of nerve
function. Stretch injuries such as those to the superficial peroneal
nerve after inversion injury of the ankle are best managed in the
acute stage by splinting the affected extremity in neutral align-
ment to minimize further nerve tension. Crush injuries should
be monitored for compartment syndrome with a low threshold
for compartment manometry and subsequent fasciotomies. All
nerve injuries should also be treated with early initiation of nerve
stabilizing medications such as gabapentin, followed by physical
therapy desensitization techniques such as contrast baths, tran-
scutaneous nerve stimulation, and range-of-motion exercises.
16
Many optimally treated patients with peripheral nerve injuries
progress to chronic neuralgia. Pharmacologic therapy should be
initiated and may include topical agents such as lidocaine patches
and capsaicin cream. Antiepileptic and antidepressant medica-
tions such as Neurontin and amitriptyline should be initiated at
initially low dosages and may be titrated to effectiveness. Physical
therapy desensitization techniques, including contrast baths,
transcutaneous nerve stimulation, and range-of-motion exercises,
are helpful as well.
Finally, surgical management may benefit patients with well-
defined nerve lesions who have failed all other treatment. Neuroma
resection with stump burial is most effective in patients who
respond favorably to diagnostic injection with local anesthetic.
Adhesive neuralgia may respond to neurolysis with or without a
vein-wrapping procedure. Patients with peripheral nerve lesions
who fail conventional pharmacologic, physical therapy, and
surgical treatment may benefit from application of an implanted
peripheral nerve stimulator.
In summary, treatment of peripheral nerve injuries involves
a multimodality approach incorporating pharmacologic agents,
physical therapy desensitization, and surgery. Treatment of
associated pathology such as ligamentous disruption, fracture, or
compartment syndrome is a prerequisite for successful treatment
of peripheral nerve injuries. Nonetheless, these injuries remain
among the most challenging conditions to treat for the occupa-
tional physician.
Figure 8c.20 Low-profile rigid foot orthosis with a Mortons forefoot
extension (Springlite Inc., Salt Lake City, UT, USA).
Chronic regional pain syndrome
Chronic regional pain syndrome may occur in response to
either noxious or nonnoxious stimuli to the extremity. Chronic
regional pain syndrome is divided into types I and II. Type I
develops after an initial event that may or may not have been
traumatic. Type II generally develops after nerve injury. Both
types I and II result in pain, allodynia (painful response to
nonpainful stimuli), and hyperalgesia often involving the entire
distal extremity. Autonomic dysfunction is common and may
manifest as color or temperature changes and hyperhydrosis. The
involved extremity may appear cool and mottled or warm,
erythematous, and swollen. Trophic changes may include a
smooth shiny appearance to the skin with thickened or thinned
toenails. Radiographs may show nonspecific osteopenia. A three-
phase, technetium-labeled, red blood cell radionuclide study
may show nonspecific periarticular uptake on all phases.
Early initiation of appropriate treatment is paramount to
successful management of this challenging disorder. Physical
therapy, medications, and regional anesthesia are all important
therapeutic tools. Lee and Kirchner
11
outlined a stepwise and
sensible physical therapy protocol. Initial therapy focuses on
mobilization and desensitization. Once the injured worker
becomes tolerant of limb manipulation, flexibility and edema
reduction techniques are used. Isotonic strengthening, stress load-
ing, and aerobic conditioning are followed by vocational reha-
bilitation, work hardening, and functional capacity evaluation.
Adjunctive medications include antidepressants such as amitripty-
line and antiepileptics such as gabapentin. Regional anesthesia
techniques may be an effective compliment to physical therapy
and medications. Lumbar sympathetic blocks or combined
somatic-sympathetic blocks may be helpful especially when
combined with physical therapy.
Crush injury
Crush injuries of the foot represent a subgroup of high-energy
foot trauma resulting in both bony and soft tissue injury with
far-reaching treatment and rehabilitation implications. The pre-
ponderance of these injuries in the industrial setting has been
well documented.
14
Crushing was responsible for 7.4% of all
foot and toe injuries incurred in private industry in 2003.
23
Management of these injuries begins with standard trauma
protocols. Once life-threatening injuries have been ruled out, sta-
bilization and assessment of the injured extremity commences.
Neurovascular examination is followed by soft tissue evaluation.
Compartment syndrome should be anticipated and early manom-
etry performed, followed by fasciotomies of the foot if compart-
ment pressures are elevated. Treatment requires aggressive surgical
decontamination, debridement of nonviable tissues, bony stabi-
lization, and early soft tissue coverage. Broad spectrum antibi-
otic coverage is required for open injuries.
Unfortunately, long-term morbidity is common after crush
injuries of the foot. Associated problems include deformity,
stiffness, chronic neuralgia, posttraumatic arthritis, and chronic
regional pain syndrome. The series of Myerson et al
14
noted that
only 46% of patients with crush injuries to the foot sustained
a good outcome. Poor outcome was noted more commonly in
those sustaining either chronic neuralgia or chronic regional pain
syndrome.
Chapter 8c Conclusion 365
RETURNING THE FOOT- AND ANKLE-INJURED
WORKER TO WORK
Correct and timely diagnosis is the first step in treatment of
the worker with foot or ankle injury. Incorrect diagnosis may
lead to unnecessary tests, inappropriate treatment, prolonged
disability, and perceptions of malingering for secondary gain
among the employer, insurance carriers, and physicians. It is
hoped that the information within this chapter may guide the
diagnostician in timely diagnosis. Nonetheless, even the most
astute diagnostician may be confounded. Early referral to an
orthopedic foot and ankle specialist may be beneficial when the
diagnosis is less than clear.
Once the diagnosis is established and treatment plans are
in place, it is important to discuss with the injured worker an
appropriate timetable for return to work. This includes a timetable
for return to modified or part-time duty. The nurse case manager
should establish whether modified duty is available. Obviously,
acutely after severe injury or surgical treatment, strict elevation
requirements make return to even sedentary duty impractical.
Once the patient can tolerate short periods with the injured
extremity in the dependent position, part-time sedentary duty
should be instituted. This may be advanced to part-time light
duty with hourly elevation breaks once weight bearing is no longer
contraindicated. As range of motion, strength, and endurance
improve through physical therapy, the work day may be elongated
until the appropriate shift length is tolerable. Functional capacity
evaluation may be useful at this point to delineate deficiencies in
task-specific functions and guide subsequent work hardening.
Work hardening may succeed in preparing the worker for his or
her previous physical work capacity. If the worker fails to meet
these expectations, an additional functional capacity evaluation
or even an independent medical evaluation may be useful.
Despite many advances in caring for foot and ankle injuries,
return to work is not always possible at the injured workers
previous occupational level. It is perhaps paradoxical and cruel
that those most likely to sustain lower extremity impairment are
those whose occupations are most dependent on lower extrem-
ity functions. For example, roofers and construction workers
are among the trades most likely to sustain a fall from a height
with a resulting lower extremity fracture. Many of these fractures
are periarticular and may result in arthritis and joint stiffness
even when optimally treated. It is easy to see how arthritis and
joint stiffness may make balancing on uneven surfaces, climbing
ladders, and negotiating scaffolding impossible. Even in the
event of a highly motivated patient and optimal treatment, the
return to a previous occupational level is not always feasible.
Should return to the previous occupation be unlikely, this should
be established with the patient as soon as possible.
CONCLUSION
In general, the treatment of foot and ankle disorders incurred
in the workplace is even more challenging than in the population
at large. Workers frequently perform demanding tasks while
standing and walking on often dynamic and uneven terrain.
Their occupation may require prolonged standing and walking
while carrying heavy objects. Furthermore, resting the injured
extremity is often difficult even when not working due to the
weight-bearing demands of everyday life. Because peoples liveli-
hoods are often at stake, timely and accurate diagnosis becomes
even more important.
The successful diagnosis of the worker with a foot and ankle
injury requires an understanding of the broad range of diagnos-
tic possibilities in the foot and ankle. In addition to fractures,
sprains, and dislocations, peripheral nerve and crush injuries
are common about the foot and ankle in the industrial setting.
A well-directed and comprehensive history and physical exami-
nation when combined with appropriate imaging studies usually
yields a correct diagnosis.
Once a clear diagnosis has emerged, a stepwise treatment
plan may be implemented. Consideration of underlying medical
conditions is an important consideration in devising a treatment
strategy. The nurse case manager and physical therapist are inte-
gral treatment team members in executing the plan of care.
Physical therapy, orthotics, functional capacity evaluations, and
work hardening are all useful treatment tools in rehabilitating the
worker as a final phase of treatment.
Restoring an injured worker to the workplace is indeed a dif-
ficult and challenging endeavor. It is hoped this chapter may
serve as a general guide to approaching the worker with a foot
and ankle ailment and thus positively impact the diagnosis, treat-
ment, and rehabilitation of these patients.
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Treatment and
Indications for Surgical
Treatment of Foot and
Ankle Injuries
Per A. F. H. Renstrm, Ulf Eklund, and Tnu Saartok
Injuries to the foot and ankle are common at work and during
recreation. The foot is an anatomic masterpiece involving
28 bones, 19 muscles and tendons, and 115 ligaments. Many of
these structures may be injured in one way or another, and it is
important to secure a correct diagnosis if treatment is to be
successful. This chapter includes a description of the different
injuries that can occur in the foot and ankle with a focus on
describing how these can be diagnosed and treated and when sur-
gery is indicated. Included is an evaluation of when it is possible
to return to work after surgery in each case.
Because the foot and ankle are pathways for the impact of body
weight and gravity, problems in these body parts are common,
especially in active people. In industrial life, not only are people
walking a great deal on hard surfaces, but they are also climbing,
jumping, and so forth, thereby increasing the risk of foot and ankle
injuries. Many of these injuries such as fractures and ligament and
tendon ruptures are acute, and their treatment is seldom controver-
sial. Probably most injuries, however, are overuse injuries that con-
stitute a great clinical, diagnostic, and therapeutic problem. In these
cases treatment and indications for surgery are often controversial,
many times because the exact diagnosis is not clear. In this chapter
we try to shed some light on these injuries, suggest indications for
surgery, and estimate the postoperative time to return to work.
ANKLE SPRAINS
In spite of the high frequency of ankle injuries, clinical diagnostic
techniques and methods of treatment vary greatly, perhaps
because the biomechanics of the ankle joint, its ligaments, and
their clinical evaluation are not fully known. The anterior
talofibular ligament (ATFL), the calcaneofibular ligament (CFL),
and the posterior talofibular ligament function as a unit. These
may alternatively resist a specific motion, so the primary stabiliz-
ing ligament depends on foot position. As the foot plantar
flexes, for example, strain in the ATFL increases, whereas that in
the CFL decreases. Although the ATFL is the weakest ligament,
it is clinically the most significant, involved as it is in 85% of
common inversion ankle sprains and in 20% of those in combi-
nation with the CFL. Clinical ligamentous damage is primarily a
function of tensile loading and is only secondarily affected by
twisting or sheer forces.
The most common mechanism of injury to the lateral ligaments
of the ankle is plantar flexion and thereafter gradually increasing
C HA P T E R
8d
progression to inversion. The lateral joint capsule tears first,
followed by rupture of the ATFL, which causes hemarthrosis and
subsequently subcutaneous ecchymosis. With further inversion,
the CFL ruptures, and the posterior talofibular and deltoid liga-
ments sustain varying degrees of injury. In acute ankle sprains,
the ATFL tears alone in 60% of cases, the ATFL tears in combi-
nation with the CFL in 20%, the posterior talofibular ligament
tears in 10%, and the deltoid ligament tears in 3%.
Treatment of severe grade III lateral ankle ligament tears has
generated much controversy, but a critical review of the literature
shows that functional treatment provides the quickest recovery
to full range of motion (ROM) and return to work and physical
activity without major residual problems.
5
Functional treatment
should include a short period of protection by tape, bandage, or
brace along with early weight bearing. In most acute cases, this is
recommended as the treatment of choice. ROM exercises and
neuromuscular training should begin early. If residual problems
persist after functional treatment, delayed surgical reconstruction
or repair can be performed even years after the injury, with
results comparable with those after primary repair.
Some authors have recommended early surgical repair of acute
severe ankle sprains in young athletes. Indications for acute repair
for athletes listed by Leach and Schepsis
7
are (1) a history of
momentary talocrural dislocation with complete ligamentous
disruption, (2) a clinical anterior drawer sign, (3) 10-degree or more
tilt on the affected side with stress inversion testing, (4) clinical or
radiographic suspicion of tears in both the ATFL and CFL, and
(5) osteochondral fracture. Most techniques described for acute
repair of ankle ligament injuries are similar. However, 10-20% of
patients treated functionally develop residual problems. If a patient
has continuous pain and swelling 3 to 4 months after an ankle lig-
ament sprain, attention should be refocused to possible intraar-
ticular (such as cartilage) lesions or other differential diagnoses.
It is very important to be aware of the many differential diagnos-
tic possibilities.
Chronic ankle instability
Chronic ankle instability may be either mechanical or functional.
Characterized by ankle mobility beyond the physiologic ROM,
mechanical instability is measurable by the anterior drawer and
talar tilt tests, respectively. Mechanical instability is considered
to be present if anterior translation is more than 10 mm (or more
than 3 mm greater than that of the uninjured ankle) or when
talar tilt is more than 9 degrees (or 3 degrees greater than the
uninjured ankle). Functional instability is a subjective feeling
that the ankle is giving way during physical activity or walking
on uneven ground. Chronic ankle instability, regardless of type,
that presents with pain, recurrent giving way, and/or positive
stress testing is an indication for operative treatment.
Surgical treatment
The combination of mechanical and functional instability is the
most frequently reported indication for delayed surgery. More than
50 procedures and modifications thereof have been described for
treating chronic ankle instability. These can be loosely grouped
as nonanatomic reconstructions or anatomic repairs. The reported
success rates for nearly all these procedures are more than 80%.
Nonanatomic reconstructions use another structure or mate-
rial to substitute for the injured ligaments in the aim to stabilize
the joint. Structures commonly used for grafting are the fascia
lata or the peroneus brevis tendon. Numerous modifications of
these classic procedures have been described.
Anatomic reconstruction is based on the 1966 Brostrm
report
3
that direct suturing and repair of chronic ankle ligament
injuries was possible and also successful promptly or many years
after the initial injury, even if the ends of the ligament could be
detected at surgery. Others reported that the elongated ligaments
had healed encased in fibrous scar tissue. Several authors reported
successful imbrication, or shortening, and reimplantation of the
ligaments to bone to achieve good results. The Peterson proce-
dure, for example, includes shortening of the ligament, repair
through bony tunnels, and imbrication with local tissue.
9
This
anatomic technique repairs both the ATFL and the CFL, whereas
most nonanatomic reconstructions, except for the Elmslie proce-
dure and the Chrisman-Snook modification, repair only the ATFL.
Repair of the CFL appears to be important, because insufficiency
of this ligament may be a factor in the development of subtalar
instability.
Anatomic repair of both the ATFL and CFL through bony tun-
nels produces good long-term results and is recommended as the
initial and standard procedure in most cases. If anatomic repair
fails, a tenodesis procedure such as the Chrisman-Snook recon-
struction is a good alternative. Nonanatomic reconstructions are
indicated in patients with moderate arthritis or generally lax joints.
After surgery and mostly depending on the pain, it is possible
to return to a desk job within 1 to 2 weeks, wearing an ankle
orthosis for about 6 weeks. However, the patient will depend on
crutches during this period. Return to walking and more active
work is possible after the healing and rehabilitation period, which
most commonly lasts 3 to 4 months after surgery.
CHRONIC ANKLE PAIN
Persistent ankle pain has been attributed to many causes, including
incomplete functional rehabilitation. It has also been attributed to
chondral or osteochondral lesions of the talus, occult fractures,
and impingement syndromes.
Osteochondral lesions of the talus
Osteochondral fracture, talar dome fracture, transchondral fracture,
and osteochondritis dissecans are currently believed to be similar
lesions. The etiology is traumatic, either as a single event or as
multiple microtraumatic insults. Osteochondral lesions are arthro-
scopically staged in four levels. Stage I is a compression injury
causing microscopic damage to an area of subchondral bone.
Plain radiographs are negative. In stage II, a partially detached
osteochondral fragment is detectable on careful examination of
an adequate series of plain radiographs. In stage III, the osteo-
chondral fragment is completely detached but remains in anatomic
position, and in stage IV, the detached fragment is displaced else-
where in the joint.
The patient usually has a history of a sprained ankle. Sometimes
a pop can be heard. With a recent injury, moderate or severe
lingering swelling of the joint can be seen. Tenderness is typically
located just distal to the anterior tibiofibular syndesmosis or
behind the medial malleolus, depending on the location of the
lesion. After an inversion injury, the symptoms of a concomitant
anterolateral osteochondral lesion may be masked in the signs
of the ligament tear.
When an osteochondral lesion is suspected, a careful plain
radiographic examination is needed with anteroposterior, lateral,
and oblique views of the ankle. Mortise views in plantar flexion
should disclose a posteromedial lesion, and the corresponding
view in dorsiflexion reveals an anterolateral lesion. If the patient
is treated for a ligament injury alone (usually immediate functional
rehabilitation), the symptoms persist, such as pain just distal to
the anterior syndesmosis, recurrent swelling, or even catching or
locking. A renewed plain radiograph investigation usually con-
tinues to be negative, calling for a bone scan of the ankle, which
is very sensitive although not specific. If the bone scan is hot
over the talus, further evaluation by plain tomography, com-
puted tomography (CT), magnetic resonance imaging (MRI), or
possibly diagnostic arthroscopy accurately determines the exact
location and extent of the lesion.
Appropriate staging and early treatment of osteochondral
lesions of the talus provide the best results. Healing depends on
capillary overgrowth of the injury site from the body of the talus.
Immobilization of the area seems to be necessary to prevent the
frictional effects of an uneven joint surface and potential progress
of the lesion into more advanced stages, leading to nonunion.
Lesions in stages I-III without established nonunion signs such
as marked sclerosis, gross uneven joint surfaces, or osteoarthrosis
are treated with a nonweight-bearing lower leg cast for
6 weeks, followed by a weight-bearing cast until radiographic
evidence shows healing. An intraarticular injection of 10 ml lido-
caine can be effective in stage I lesions. Delayed nonoperative
treatment of stage III lesions often fails. These lesions, as well as
stage IV lesions, are often treated early surgically to prevent further
deterioration of the joint. An experienced arthroscopic surgeon
reaches many of these lesions arthroscopically (removal of the
detached lesion and debridement of the lesion bed), but open
approaches are occasionally needed. Reattachment of the osteo-
chondral lesion might be considered in the acute phase. Proper
intraarticular access occasionally requires osteotomy of the medial
or lateral malleolus. If an osteotomy is performed, it is essential
that subsequent internal fixation is rigid to allow the important
early motion in rehabilitation. Postoperative weight bearing is
delayed 2 to 6 weeks (a full 6 weeks if osteotomy of the medial
malleolus was performed).
The prognosis after early nonoperative treatment in stages I-III
is good in 75% of cases. The results of surgery are mixed, with
reports that it yields a 40% to 80% rate of good results in late
stage III and in stage IV lesions. Advanced lesions, where treat-
ment has been delayed more than 1 year, historically have had a
poor outcome.
8
More recent treatment options such as osteo-
chondral grafting or autologous chondrocyte transplantation,
however, seem to yield promising results.
Return to work that involves walking is possible within 2 to
3 months of nonsurgical treatment and 1-4 months after surgery,
depending on the extent of the lesion and the method used.
Chapter 8d Treatment and indications for surgical treatment of foot and ankle injuries 368
Loose bodies in the ankle
Typically seen on plain radiographs, loose bodies in the ankle are
often related to intermittent pain, swelling, and clicking. They
emanate either from a stage IV transchondral fracture of the
talus, from osteophytes on the anterior distal rim of the tibia or
the dorsal neck of the talus, or, if multiple, from synovial osteo-
chondromatosis. Posteriorly located loose bodies must be dif-
ferentiated from an extraarticular os trigonum. Chip fractures
may appear as loose bodies as well. Pure chondral loose bodies
from lesions in the tibial plafond, in the talar dome, or from
synovial chondromatosis cause the same symptoms. If plain radi-
ographs are negative, however, more advanced measures such as
MRI or arthroscopy are needed. Arthroscopic removal of loose
bodies by a skilled arthroscopic ankle surgeon is the treatment of
choice. Return to walking work is possible after 2-6 weeks.
Impingement syndromes
Impingement synovitis of the lateral ankle after an inversion
injury is not uncommon. Symptoms can fully mimic those of an
anterolateral talar osteochondral lesion. Radiographic evaluation
such as contrast-enhanced MRI used for detecting osteochondral
pathology should reveal soft tissue abnormalities also. In the
absence of concomitant chronic ligamentous instability, treat-
ment of impingement synovitis involves the surgical removal of
impinging tissue by way of the arthroscope. When lateral liga-
mentous insufficiency is present also, open removal of impinging
chronic synovitis tissue together with an appropriate stabilizing
procedure is recommended. Provided that no chondral lesions
are present, postoperative results are generally excellent.
Residual symptoms after ankle inversion sprains are quite
common and are most often due to both mechanical and func-
tional instability of the joint. Occasionally, however, anterolat-
eral ankle pain and a feeling of giving way persist in spite of
normal stability and well-performed functional rehabilitation.
Examination reveals tenderness just anterior to the lateral malle-
olus, especially in dorsiflexion. Additionally, at times a snapping
phenomenon from this region can be elicited when the foot is
tested for inversion stability. In these instances, a meniscoid lesion
of the ankle should be suspected. In such cases, both radiographs
and bone scintigraphy are normal, thereby excluding osteochon-
dral lesions. A possible etiology is local fibrosis that has developed
after posttraumatic impingement synovitis after the inversion
injury. Possibly torn strands or distal parts of the ATFL are caught
in the talofibular joint, with subsequent synovitis and ultimately
fibrosis developing. An intraarticular injection of 10 ml lidocaine
may limit the pain. Together with a limited dorsiflexion, this test
with local anesthesia secures the diagnosis.
On surgical exploration, which is readily done arthroscopi-
cally, the lesion has a hyalinized meniscoid appearance. In most
patients, simple excision of the lesion and surrounding reactive
synovitis leads to full recovery.
After an impingement syndrome that involves impingement
synovitis or a meniscoid lesion that has been treated surgically,
return to work may vary but should be possible within 1 to
3 months, depending on the type of job. The results and the
prognosis after surgical treatment are usually good.
Osteophytes at the anterior rim of the tibia, often called
soccer players ankle, is a condition with decreased dorsiflexion
and pain over the anterior part of the ankle joint. Dorsiflexion is
blocked because of the formation of osteophytes on the distal
anterior rim of the tibia and sometimes on the corresponding
area of the dorsum of the talar neck. The osteophytes probably
result from repetitive traction microtrauma to the ankle joint
capsule with subsequent bleeding and ultimately reactive osteo-
phyte formation. The history, clinical examination, and plain radi-
ographs reveal the condition. Apart from soccer, the condition is
seen also in sports such as American football and orienteering
but only rarely in recreational athletes. The incidence in workers
is unknown, but in occupations requiring repetitive traction of
the anterior capsule of the ankle, this condition may appear.
Although ankle dorsiflexion is not always fully restored, removal
of the osteophytes openly or arthroscopically, followed by rapid
rehabilitation consistently yields good or excellent results.
After an impingement syndrome due to anterior osteophytes,
return to work should be possible within 1 to 3 months, depend-
ing on the type of job. The results and the prognosis after surgical
treatment are usually good.
Sinus tarsi syndrome
Patients with a history of multiple lateral ankle sprains occasion-
ally have residual pain and tenderness to palpation 2 cm anterior
and distal to the tip of the lateral malleolus. This area, the sinus
tarsi, is a funnel-shaped cavity bordered by the talar neck superi-
orly, the anterolateral calcaneus inferiorly and posteriorly, and
the interosseous talocalcaneal ligament anteriorly. Recurrent
subtalar sprains may cause microruptures in this broad flat liga-
ment, leading to a chronic inflammatory reaction. The diagnosis
is determined from the patients history and localized tenderness
slightly but significantly distal to the ATFL. Usually, subtalar
motion is impaired and may present with dull pain. Typically,
ankle joint stability is not affected. Radiographs are negative, so
the easiest way to diagnosis is a local anesthetic block into the
sinus tarsi, which gives immediate pain relief.
Initial treatment consists of rest and nonsteroidal antiinflam-
matory drugs (NSAIDs). Steroid injection into the sinus tarsi has
proven helpful.
6
In the rehabilitation phase, peroneal remobiliza-
tion is emphasized because a sinus tarsi syndrome may be related
to functional instability of the ankle joint. In the rare cases where
symptoms persist, surgical decompression, that is, excision
of the sinus tarsi contents (ligaments, fat), has been successful.
Return to work may vary but is often possible 1 to 2 months
after surgery.
Arthrosis of the ankle
Compared with that of the hip and knee, the incidence of ankle
arthrosis is low. It is most commonly seen after a fracture around
the ankle, especially when fracture healing was allowed in a
nonanatomic position. This leads to incongruency of the ankle
mortise and often to rapid development of arthrosis. Other predis-
posing factors include severe ligamentous laxity and stage III-IV
osteochondral lesions of the tibial plafond or the talar dome.
Chapter 8d Chronic ankle pain 369
As yet, no curative treatment has been found for articular sur-
face injury and/or degeneration. Symptomatic treatment aiming
at unloading the surfaces and reducing the reactive inflammation
is easy and often very helpful for pain control. Especially with
catching and locking sensations from detached osteophytes or
pieces of cartilage, arthroscopic or open debridement and loose
body removal may occasionally be an option. In severe cases,
more extensive treatment must be considered; ankle arthrodesis
is a reliable and well-proven way to relieve pain. Empirically, the
functional disability of the arthrodesis often is well compensated
in young patients. In selective cases where the ankle mobility and
soft tissue quality are preserved, total ankle replacement is a recent
treatment alternative. Return to work is often possible 1-2 months
after arthroscopic procedures but may take 3-6 months after
arthrodesis or total ankle replacement.
TENDON INJURIES AROUND THE ANKLE
Traditionally, the term tendinitis has been used to describe most
tendon overuse injuries. The tendon itself, however, consists of
dense connective tissue with little inherent vascularity and is not
predisposed to inflammatory change. Instead, the term tendinosis
is used to define structural, most often degenerative, tendon
changes. The surrounding tendon sheath, the peritenon, is usually
highly vascularized and subject to inflammation or peritendinitis
(paratenonitis) when overused. Tendon disease (excluding ruptures)
can thus be described as tendinosis, peritendinitis (paratenonitis),
or a combination. The symptom of pain from the tendon itself
or paratenon is usually termed tendinopathy.
Achilles tendon overuse injuries
Achilles tendon overuse injuries are common. Predisposition to
these injuries can result from a number of intrinsic and extrinsic
factors: lower extremity malalignment such as hyperpronation,
increased femoral anteversion, or cavus foot and a tight Achilles
tendon with poor flexibility. In recreational running athletes, poor
shoes, hilly tracks, and training errors (such as sudden changes
in mileage or speed and improper warm-up and cool-down) are
related to heel cord overuse problems. The main symptom is
pain, typically located 2-6 cm above the Achilles tendon insertion
on the calcaneus. This region of the Achilles tendon complex
is considered vulnerable and prone to overuse because of poor
vascularity. Physical examination should include an evaluation of
alignment and flexibility of the heel cord and inspection/palpation
of the cord, the insertion, and the retrocalcaneal area, respectively.
Four major differential diagnoses must be considered:
1. Peritendinitis is manifested as inflammation of the surrounding
paratenon with crepitation occasionally present.
2. Tendinosis, or degenerative changes within the tendon itself, is
characterized by gradual onset of pain and stiffness and localized
tenderness and swelling of the tendon complex.
3. Partial rupture typically causes a sudden onset of pain.
The condition is relatively rare and must be distinguished
from the much more common total tendon rupture discussed
below. Clinical examination reveals localized swelling and
distinct tenderness. The healing potential of partial Achilles
tendon tears is poor, with more than 80% of patients having
residual problems after 5 years.
1
4. Retrocalcaneal bursitis, an inflammation of the bursa between
the calcaneus and the anterior aspect of the Achilles tendon,
is characterized by pain combined with tenderness and swelling
anterior to the distal part of the heel cord. With time and
when left untreated, the anterior fibers of the tendon insertion
are severed, necessitating more extensive treatment and pro-
longed recovery period.
Except in cases of partial tears, treatment of Achilles tendon
overuse injuries is primarily conservative, the cornerstones being
correction of malalignment, ice, and, most often, medication for
pain control, ankle ROM exercises, and both stretching and
strengthening of the plantar flexors and dorsiflexors of the ankle.
For tendinosis types of lesions, daily eccentric strength training
of the gastrocsoleus complex has proven successful in about 7 of
10 patients and is now considered to be the initial treatment and
rehabilitation for most cases of tendinopathy. A 1-cm heel wedge
can be useful also in reducing symptoms during daily activities
like walking. We strongly advise against the use of local cortico-
steroid injections in the treatment of heel cord injuries.
If conservative measures fail in spite of a 3- to 6-month period
of adequate rehabilitation, surgery is indicated. Preoperatively,
radiographic investigation excludes calcifications, and MRI or
ultrasonography reveals the extent of structural changes within
and around the tendon. These images help the surgeon chose
and plan the appropriate procedure. Recently, Doppler-ultrasound
investigations have been shown to reveal the presence of any patho-
logic neovessel formations anterior to the tendon, which seemto be
associated with the pain of Achilles tendinopathy.
Experimentally, ultrasound-guided sclerosing injections of the
neovessels anterior to the tendon have shown promising results
in control of the pain. Surgery for chronic peritendinitis includes
removal of the thickened, scarred paratenon. A partial tear or
tendinosis involves an incision longitudinally in the tendon and
careful removal of pathologic tissue, after which the tendon
should be closed carefully by adapting sutures side to side. In
retrocalcaneal bursitis, the bursa should be removed and an exci-
sion osteotomy of the superior corner of the calcaneal tuberosity
should be carried out. Postoperative care usually involves immo-
bilization for about 10 days followed by mobilization that allows
plantar flexion of 0-20 degrees in a walking boot. With appropriate
indications and carefully monitored postoperative rehabilitation
for 4-6 months, surgery yields good results in more than 80%
of patients.
After surgery, return to work depends on the diagnosis and
the type of job. The patient can return to desk work within the
first week but should keep the leg elevated. If the patient has
mobile work that includes much walking, he or she can return to
limited activities after 1 month using the walking boot. Return
to full activity is usually possible 3-4 months after surgery. After
sclerosing injections, the amount of pain reduction controls the
return to work, which may vary significantly from 2-4 weeks to
months.
Another diagnosis to consider, complete Achilles tendon rup-
ture most commonly occurs in active people around 40 years
of age. As learned from sports activity, the most common injury
situation involves a sudden change of motion, including dorsal
ankle hyperextension. The typical history is a sensation of sudden
pop and immediate but moderate local pain. Injured people often
believe that somebody has hit the ankle from behind. Failure or
impaired ability to plantar-flex the foot is typical as shown by
squeezing the unweighted calf muscles (Thompsons test). Before
significant local swelling sets in, there is a clearly palpable gap at
rupture level, typically 2-6 cm above the distal insertion.
Recommended treatment for active people is most commonly
surgical, allowing early tension to be put on the tendon for
proper orientation of the healing collagen and better possibility
to regain full strength. Early motion in the form of plantar
flexion from 0 to 20 degrees is permitted after 1 week, and the
patient can walk with this ROM in a walking boot after 2-3 weeks.
The boot is usually discarded after 6 weeks. An alternative option
for less active people, nonsurgical treatment involves at least
6-8 weeks of immobilization and a longer rehabilitation. With
nonsurgical therapy, the risk for rerupture is much higher, and
early motion is not possible.
After a complete Achilles tendon tear, return to a desk job
depends on crutch walking but is possible within 3 to 5 days
regardless of treatment. If surgery has been performed, the
patient can often walk reasonably well within 1 month using a
walking boot and can walk properly and resume full activity
3-4 months after surgery. After nonsurgical therapy, return to
demanding physical activity or work is usually not possible for
4-9 months.
Peroneal tendon injuries
The peroneus longus and brevis tendons run down the lateral
aspect of the ankle and midfoot to their insertions on the plantar
side of the medial side of the midfoot (first metatarsal, medial
cuneiform, and navicular) and on the proximal end of the fifth
metatarsal, respectively. The tendons pass behind the lateral malle-
olus beneath the two retinacula, which hold them in position.
Peroneal peritendinitis or tendinosis is typically elicited via
stenosis under these retinacula. A longitudinal tear can occur as a
result of either acute trauma or overuse. A common predisposing
factor to the various forms of peroneal tendon disease is distortion
of the local anatomy caused either by a fracture of the lateral malle-
olus or the calcaneus or by an ankle sprain. Pain, swelling, and joint
sheath tenderness are located posterior and inferior to the lateral
malleolus. Pain may be increased on weight bearing, but forced
plantar flexion and inversion as well as resisted eversion of the
ankle are even more painful. Physical examination must include an
evaluation of tendon stability as discussed below. Subtalar motion
usually is decreased. Primarily nonsurgical, treatment includes
active rest, ice, NSAIDs, and crutches as acute measures. The addi-
tion of casting or a walking boot can possibly be helpful in some
patients. Surgery to correct the cause is only occasionally necessary.
Recurrent subluxation or dislocation of the peroneal tendons
is an important differential diagnosis. The initial mechanism for
this injury involves significant internal rotation in combination
with inversion. There is sudden pain and a sensation of dislocation
or subluxation over the lateral malleolar region.
Treatment of these injuries is normally surgical; however, a
nonoperative approach using a below-knee cast may be war-
ranted in the acute setting. For recurrently disabling dislocations
or subluxations, tendon stabilizing surgery that imbricates or
reconstructs the stabilizing retinacula is the only meaningful treat-
ment. Deepening of the peroneal groove is sometimes indicated.
If the tendon has also a chronic pathologic condition, surgical
incision and removal of the pathologic tissue can be valuable,
although this procedure is not very common.
After surgery, return to a desk job wearing a cast or a walking
boot is possible within the first week. For people with more
demanding duties, however, the rehabilitation time is 6 weeks in
a walking boot followed by 6 weeks of rehabilitation, making
return to harder labor possible after 3-4 months.
Flexor hallucis longus tendon
overuse problems
Overuse problems in the flexor hallucis longus tendon complex
are common in ballet dancers because of frequent and forceful
plantar flexion of the ankle and great toe (pli and point work).
Repetitive push-off maneuvers also transmit substantial forces
across the tendon and its sheath with possible irritation, swelling,
and nodulus formation following.
The result is pain and sometimes catching or even locking of
the tendon, so-called functional hallux rigidus. Symptoms are
most often located behind the medial malleolus where the tendon
passes through a narrow fibrous tunnel, thereby predisposing to
impingement. Other tight areas for flexor hallucis longus tendon
passage are under the base of the first metatarsal and between the
great toe sesamoids.
Therapy consists of active rest, ice, NSAIDs, and crutches
in the acute phase. A longitudinal arch support with firm soles
is often helpful. Pli and point work in dancers, as well as
similar forced toe-off exercises in labor, must be avoided until
the patient is symptom free. If symptoms persist, especially if
they are stenotic, surgery is indicated. At surgery, the fibrous
tunnel is divided, and tenosynovectomy and tendon debride-
ment are performed. When explored, local swelling of the
tendon proper often reveals a partial rupture, necessitating
scar tissue excision and tendon reconstruction. Postoperatively,
the ankle is immobilized up to 10 days followed by a rehabilita-
tion program for at least 1-2 months. Whereas return to desk jobs
can occur within weeks, hard labor becomes possible after
2-4 months.
Tibialis posterior tendon overuse problems
Posterior tibial tendon injuries due to overuse are seen in young
active persons such as runners. Hyperpronation is a strong pre-
disposing factor because mechanical demands on the tendon along
its course behind the medial malleolus to the insertion on the
navicular bone are significantly increased. Repetitive microtrauma
leads to inflammation in the tendon sheath followed by partial
tears and scar formation in the tendon itself. Complete ruptures
are seen mostly in the elderly. Long-standing unidentified
Chapter 8d Tendon injuries around the ankle 371
posterior tibial tendon ruptures or other causes of tendon
insufficiency result in a unilateral flatfoot and highly or totally
impaired independent toe rise.
Clinical findings include tenderness and often swelling
along the course of the tendon behind and beneath the medial
malleolus. Early on, crepitus is frequently present. Passive prona-
tion or resisted supination of the midfoot exacerbates the pain.
Treatment in the acute phase includes active rest, ice, NSAIDs,
and a medially posted orthotic. In severe cases, a short leg
nonweight-bearing cast or walking boot for 2 weeks usually
relieves the pain. After careful biomechanical evaluation,
patients with flatfoot deformities need more advanced orthotic
treatment. In chronic cases, surgical exploration is considered to
address potential tenosynovitis, tendinosis, tendon tear, and steno-
sis along the tendon course.
Return to work depends on the resolution of pain. After surgery,
2 to 4 months is often needed for healing and rehabilitation before
pain-free walking is possible.
SUBTALAR JOINT INJURIES
Subtalar joint dislocations
Subtalar joint dislocations or subluxations are infrequent, but when
occurring they are caused by a fall from a height or a traffic accident.
Substantial torsional force is required to accomplish these partial
or total dislocations due to the pronounced inherent bony and
ligamentous (medially the deltoid and laterally the calcaneofibu-
lar and talocalcaneal) stability of the subtalar joints. These
injuries are classified according to the direction taken by the foot
in relation to the talus, thus medial, lateral, posterior, or anterior.
Medial dislocation is by far the most common subtalar dislocation
reported, the injury mechanism being forced inversion. The condi-
tion is very painful to the hindfoot, and the deformity in total
dislocations is marked, with the midfoot and forefoot severely
adducted. Prompt management is crucial because of potential com-
promise of neurovascular structures. Anteroposterior and lateral
radiographs of the ankle and foot are taken without delay.
Fractures of the malleoli, talus, fifth metatarsal, or navicular some-
times accompany these injuries. An attempt at closed reduction
under intravenous sedation may be justified, but if not successful,
immediate open surgical reduction must follow. Once reduced, the
subtalar and talonavicular joints are typically stable, and no inter-
nal fixation is needed. Postoperatively, immobilization in a short
leg nonweight-bearing cast for 3 weeks is recommended, fol-
lowed by gradual ROM exercises and progressive weight bearing.
Provided that subtalar dislocations are treated promptly and
reduction is successful, the prognosis is satisfactory in many
patients. Severe soft tissue problems and associated fractures tend
to worsen the outcome. Late complications include impaired
subtalar motion, arthrosis of the joints affected, and persistent
swelling and pain. In those cases, a subtalar arthrodesis is some-
times warranted.
Return to work depends on the resolution of pain. After suc-
cessful closed reduction, the return to desk jobs is possible within
weeks, whereas surgical intervention often requires a rehabilita-
tion time of 2-4 months before the patients return to physically
more demanding jobs.
FRACTURES
Fracture of the talus
The talus holds a key position in the ankle joint, that of linking
the leg and the foot. It articulates to the tibia and fibula, calcaneus,
and navicular. More than 60% of the surface is covered with
articular cartilage, which leaves only a limited area for nutritional
blood supply. Talar blood supply may be easily compromised
with trauma and/or surgery in this region.
Apart from the common minute avulsions from the lateral
part of the talar neck after lateral ankle sprains, substantial
trauma is required to fracture the talus. Most commonly, a talar
neck fracture is sustained from a forceful passive dorsiflexion of
the ankle joint, as occurs when landing on the feet after a fall
from a height. In this situation, the anterior margin of the distal
end of the tibia is thrust into the dorsal talar neck. The patient has
significant ankle swelling and pain. Radiographs give details as to
the fracture pattern and possible subluxation or dislocations.
Displaced fractures require reduction and rigid fixation,
followed by early nonweight-bearing ROM exercises. For undis-
placed fractures, 6-8 weeks of immobilization in a neutral-
position short leg cast is recommended. Weight bearing is delayed
until radiographic union is evident.
The prognosis after displaced unreduced fractures is poor.
Better results are achieved after anatomic reduction and stable
screw fixation. Even with apparently nondisplaced fractures, how-
ever, ankle joint arthrosis develops in one third of the patients at
late follow-up.
Return to work depends on the outcome of fracture
treatment. In successful cases, patients may return to manual labor
in 3-6 months, but nonunions and ankle joint arthrosis may lead
to life-long handicaps.
Fractures of the calcaneus
As with talar fractures, substantial force is required to fracture the
calcaneus. Landing on the heel after a fall or jump from a height
is the most frequent injury mechanism. Partly because of the
associated significant swelling, a calcaneal fracture is very painful.
Initial care should always include strict elevation of the foot
above the heart level of the patient. Plain radiographs yield the
diagnosis, but further imaging using CT gives additional valuable
information regarding the extent of the fracture and its effect on
the subtalar joints. The risk of compartment syndrome in the
intrinsic muscle compartments of the foot necessitates monitoring
the clinical course and compartment pressures and performing a
fasciotomy when indicated (pressure above 35 mm Hg) to prevent
ischemic muscle injuries and clawing of the toes.
The treatment of calcaneal fractures is still controversial. Because
of the topographic complexity of the bone and the variable fracture
patterns, it is difficult to obtain comparable groups when different
treatments are evaluated. A full spectrum of treatment modalities
ranging from reduction, surgery, or immobilization, to closed
reduction and immobilization, to open reduction and internal
fixation is used. At present, however, surgical treatment is increas-
ingly favored. The main indications for surgical intervention are
severely disrupted posterior subtalar facets, significant upward
displacement of the calcaneal tuberosity, or valgus displacement
of the tuberosity of the calcaneus with abutment against the lateral
malleolus.
If a nonoperative approach is chosen, early motion is recom-
mended, whereas weight bearing is delayed for at least 8 weeks.
Operative treatment requires care by an orthopedic surgeon with
extensive hindfoot fracture experience.
Regardless of treatment, the long-term prognosis after calcaneal
fractures is guarded. Eighty to 90% of patients have residual
symptoms. Typically, subtalar mobility is significantly inhibited.
In many cases, a permanent custom-made heel orthotic is required
to control pain and swelling.
Depending on the location and extent of the injury, return to
work varies but takes at least 3-6 months if repetitive weight bear-
ing is demanded in the job. It is sometimes impossible to return
to hard work because of persistent pain during walking.
STRESS FRACTURES
Stress fractures of the foot and ankle
Stress fractures of the foot and ankle, typically in the distal fibula,
tibia, calcaneus and navicular bone, and metatarsals, are common
in athletes and probably workers. Bone is continuously adapting
to new loading patterns. A stress or fatigue fracture is the failure
point in this normal adaptive process. Pain in the periosteum is
an early warning sign of overloading. If fatigue and microdamage
occur too rapidly, new bone cannot develop fast enough, the bone
weakens, and a stress fracture may gradually develop.
During gait the muscles play a major role in energy absorption.
Muscle fatigue impairs shock absorption, leading to altered stress
distribution and increased compressive loads on the bone with a
greater risk for stress fracture. A complementary contributing
factor in the possible development of a stress fracture is biome-
chanical imbalance such as skeletal asymmetry and leg length
discrepancy. A short leg is more susceptible to stress reaction
and fracture. Some anatomic abnormalities predispose to stress
reactions, although unpredictably. A rigid foot, for example, puts
increased stress on the metatarsals. Hard surface running places
the second metatarsal at risk if a tight heel cord, a long second
metatarsal, or a flexible nonsupportive great toe is present also.
Other factors include exercise or prolonged walking on hard
surfaces, improperly supportive shoes, and injury to the opposite
extremity, causing the patient to protect the injured limb by
placing more weight on the contralateral limb.
The common clinical course includes insidious onset of pain
that initially is vague. With continued stress, pain increases and
becomes more localized with possible soft tissue swelling. Clinical
examination reveals distinct tenderness over the lesion. The early
diagnosis is verified by scintigraphy or MRI followed by CT,
whereas plain radiographs typically become positive at 3-8 weeks.
Treatment consists of activity modification to the limits of comfort.
Nongravity exercises are initiated, and casting is recommended
only with multiple fractures, intolerable pain, or fragmentation.
Healing of a properly treated stress fracture occurs in 1-4 months
but could take 6 months. A useful clinical healing test is having
the patient hop on the affected limb without pain. In multiple
or recurrent stress fractures, screening for endocrine and/or nutri-
tional dysfunction, especially in underweight persons, is indicated.
Hindfoot stress fracture
Although relatively uncommon, calcaneal stress fractures have
been reported in military recruits in vigorous physical training for
more than 16 hours a day. Diffuse pain about the heel is aggra-
vated by its compression from a medial to lateral direction. Pain
is not localized only to the plantar aspect of the heel. Treatment
includes weight bearing with crutches as tolerated, a shock-
absorbing heel insert, and pain control as required. At least
8 weeks are usually required for healing. The regimen of no-weight
or partial weight bearing of these injuries makes it possible for
white-collar workers to return to their jobs within weeks, whereas
the return to heavy and demanding labor may take several months.
Metatarsal stress fractures
Every fifth stress fracture (17-20%) in the lower extremity is located
in the metatarsals, and the second ray is the most common site.
Surgery for hallux valgus is related to stress fracture of the second
metatarsal because of altered loading patterns. Hypermobility of
a metatarsal can predispose to adjacent metatarsal stress fracture.
Typical locations of metatarsal fractures are first metatarsal-medial
base, second and third-distal diaphysis, fourth-middle or distal
diaphysis, and fifth-proximal (junction metaphysis/diaphysis).
Symptoms typically progress slowly in a crescendo effect. It can
take 1-2 months or more before stress fractures become visible on
plain radiographs. A bone scan, MRI, or possibly CT is the key
to early radiographic confirmation of a stress fracture.
Metatarsal stress fractures are generally treated nonoperatively;
early in nondisplaced fractures, activities are limited for 4 weeks.
Running in 3-4 feet of water is beneficial, because the forefoot
then usually is protected from heavy repetitive loading.
Stress fractures through the fifth metatarsal, however, need
special attention. Nonoperative treatment implies 6-8 weeks
of nonweight-bearing casting. Less restricted nonoperative
treatments have shown high failure rates. An increasing number
of investigators advocate early internal fixation because this
markedly decreases healing time and return to strenuous activities.
4
Signs of chronicity of the fracture, such as cortical thickening
and intramedullary sclerosis, strongly indicate that only open
treatment will be successful. Surgical alternatives are curettage,
bone grafting, and cerclage fixation of the fracture; drilling of the
medullary canal followed by malleolar screw fixation without
opening the fracture; or combinations of these. Postoperative
casting time varies from 2 to 8 weeks, and the return to strenu-
ous activities, or heavy labor, requires clinical and radiographic
evidence of healing, most often 8-12 weeks.
Hallux sesamoid stress fractures
Hallux sesamoid stress fractures are rare, much rarer than
sesamoiditis, a difficult differential diagnosis. Bipartition of a
sesamoid is not uncommon, so radiographic diagnosis is difficult
also. Furthermore, scintigraphy in both stress fractures and
sesamoiditis is positive. Stress fractures, however, do not heal
with immobilization or prolonged inactivity. If other causes of
pain can be excluded, a sesamoid stress fracture is treated with
excision of the bone, with usually a good outcome thereafter.
It should be noted that surgical access to the lateral sesamoid is
Chapter 8d Stress fractures 373
difficult and its safe removal requires significant surgical experi-
ence in this area.
Tarsal navicular stress fracture
In nonathletes, navicular stress fractures are uncommon. The con-
dition is characterized by an insidious onset of vague arch pain,
increased pain in the midfoot with motion, and limited dorsi-
flexion of the ankle. Activity increases the discomfort. Typically,
but not always, tenderness is localized over the navicular bone.
Plain radiographs are most often normal, and a bone scan (or MRI)
is required for diagnosis. Plain tomography or CT also may
delineate the extent of the injury. The fracture is typically sagit-
tally oriented in the central third of the bone, due possibly to the
relative avascularity of this part of the navicular. Treatment of
acutely displaced fractures calls for open reduction and internal
fixation. To heal uneventfully, nondisplaced fractures should be
treated with a nonweight-bearing cast for 6-8 weeks. In patients
not casted or those given a weight-bearing cast, the complication
rate is high with delayed union, nonunion, or recurrence of
the fracture, calling for surgical bone grafting. Postoperatively,
the lower leg is immobilized in a nonweight-bearing cast until
union has occurred, which may take 2-4 months. After surgery,
return to a desk job is possible within a week, whereas resump-
tion of weight-bearing or other types of heavy work may take
3-4 months.
HEEL PAIN
Heel pain is a common and potentially disabling condition with
many possible causes. Distinction of these is important because
treatment and the expected outcomes differ.
A thorough history of the patients complaints and pain and a
careful physical examination are mandatory tools in establishing
a correct diagnosis. These include an evaluation of the patients
characterization of the pain, including onset, duration, nature, locali-
zation, and relation to work and/or physical activity. Alignment of
the lower part of the leg, ankle, and foot; the ROM of the ankle
and subtalar joints; and the status of the longitudinal and trans-
verse arches of the foot should be determined. Skin abnormalities
such as discoloration, wounds, bumps, blisters, and tender areas,
including reactions to the tapping of nerve branches (Tinels sign),
should be noted.
Heel pain syndrome
Pain localized over the origin of the plantar fascia on the antero-
medial calcaneal tuberosity is termed heel pain syndrome or
plantar fasciitis. Preceded by overuse, the onset is insidious.
The pathogenesis is believed to be traction periostitis and
microruptures of the origin of the plantar fascia. Symptoms
include morning stiffness and pain that resolve during the day.
Pain increases after prolonged walking, however, and jumping
and running can be intolerable. Palpation reveals pain in the
very localized area just described that is typically not elicited
with passive dorsiflexion of the toes, which causes traction on
the plantar fascia. Plain radiographs are negative and may or may
not show a calcaneal spur.
Conservative treatment consists of active rest, pain control with
NSAIDs, and usually an orthotic device (shock-absorbing heel cup
or a custom-made nonrigid orthosis). Stretching exercises of the
plantar fascia and the Achilles tendon are advocated. Within a
3-month time frame this treatment is usually successful, but up to
1 year may be required in some cases. In refractory cases, a corti-
costeroid injection may be considered, but it is crucial that the cor-
tisone is deposited deep to the plantar fascia to avoid plantar fat
pad atrophy. In the few cases in which disabling symptoms persist,
surgical treatment such as proximal plantar fascia release is indi-
cated. The time needed for healing and rehabilitation is 2-5 months.
Heel spurs
The relation between plantar heel pain and a heel spur on radio-
graphs is considered to be very poor. Only half of the patients with
heel pain have a spur, and of all people with a heel spur, only 10%
to 15% have heel pain. Indeed, a heel spur, when present, is located
deep to the origin of the plantar fascia, in the nonweight-bearing
substance of the flexor digitorum brevis muscle.
Plantar fasciitis
True plantar fasciitis is an inflammation of a greater part of the
plantar fascia, with pain on passive dorsiflexion of the toes
and tenderness over the proximal area of the plantar fascia.
Symptoms therefore predominate in the plantar aspect of the
midfoot rather than the heel. Special orthotics designed to
relieve the pressure on the plantar fascia should be used. If symp-
toms persist in spite of adequate rest and orthotic use (at least 3-
6 months), surgery such as proximal plantar fascia release should
be considered.
Plantar fascia rupture and heel
spur fracture
Plantar fascia rupture and heel spur fracture are characterized by
pain in the same area as in heel pain syndrome, but the onset is
sudden. Ruptures of the plantar fascia are not common, but these
are reported most often in the literature after cortisone injection
in the plantar fascia.
In patients with acute trauma or persistent pain, a special x-ray
projection (45 degrees medial-oblique) that can reveal a fractured
spur should be taken. Treatment is primarily conservative: active
rest, NSAIDs, crutches, and very gradual resumption of weight-
bearing activities over a 6- to 10-week period. If symptoms per-
sist and nonunion is suspected, surgical removal of the detached
fragment must be considered.
Fat pad atrophy
The plantar fat pad of the heel is a highly structured tissue
designed to withstand repetitive impact loads. If the structure fails,
as could happen after long-time overuse, the shock-absorbing
capacity of the tissue markedly decreases, usually resulting in pain.
On clinical examination, the heel pad feels softer and thinner with
the underlying calcaneal tuberosity readily palpable. Maximum
tenderness is located centrally on the weight-bearing area of the
heel, as opposed to the anteromedial tenderness location in heel
pain syndrome. Treatment is nonsurgical, using support with a
cushioned heel cup and soft-soled shoes. Because they may aggra-
vate the atrophy, local cortisone injections are contraindicated.
Fat pad inflammation
Inflammation of the fat pad produces symptoms similar to those
of fat pad atrophy except for the lack of palpable thinning or
softening of the heel pad. In this situation, the supportive heel
cup should be semirigid rather than cushioned. Prognosis is
usually good, but symptoms may need over 6 months to resolve
completely. Again, local cortisone injections are contraindicated.
After a period of heel pain, return to work varies with the var-
ious diagnoses as described above. Most people can work during
nonsurgical treatment of heel pain, but walking should be
restricted. After surgery for heel pain (which involves mostly
release of the plantar fascia), the healing and rehabilitation time
needed to return to walking is usually around 2-4 months.
Sometimes tenderness remains, and the rehabilitation time may
then be prolonged.
NERVE INJURIES
Manifestations of peripheral nerve injuries include paresis/paralysis
of extrinsic and intrinsic muscles, sensory defects, pain and con-
tractures, and a risk for secondary changes such as pressure ulcers
and neuropathic arthropathy. In a neurologic examination of the
foot and ankle, careful assessment of sensory, motor, and sympa-
thetic function is important. The examination should include
evaluations of gait, heel and toe walking, and the Trendelenburg
sign in the hip. The presence of muscle paralysis, stiffness,
contracture, spasticity, ataxia, pain, and fixed or functional pres-
ent deformity should be registered. Foot contractures are studied
first with flexed knees, then with straightened knees to evaluate
the effect of the heel cord on the deformity. Cavus, planus, varus,
valgus, and equinus of the whole foot and forefoot are assessed
together with flexibility of the arches as well as claw toes or
hammer toes. Skin moisture reflects sympathetic function, and
peripheral nerve disease is often accompanied by sympa-
thetic degeneration with resulting dry, thin skin. Tinels sign is
closely evaluated as regards presence, intensity, and location.
Documentation with drawings and photographs of areas with
nerve dysfunction is very helpful in the assessment and treat-
ment of nerve disorders.
Causalgia, or reflex sympathetic dystrophy, is characterized
by overactivity of the sympathetic nervous system because of
irritative lesions of sympathetic nerve fibers. Burning pain and
dry hot skin are typical manifestations. A sympathetic nerve block
often improves symptoms.
Charcot deformity is a joint deformity that can occur in con-
junction with any neuropathy, with sensory deficit developing in
a joint subjected to loading of the body weight. This is commonly
seen in the midfoot joints in conjunction with diabetes mellitus.
Classification
Five degrees of nerve injury are traditionally distinguished, depend-
ing on the severity:
I. First degree: Conduction deficit, axon intact. Prognosis is good.
II. Second degree: Axon severed but intact endoneurium,
Wallerian degeneration. Regeneration follows the pattern of
regrowth. Axon regeneration averages 1 to 2 mm/day and is
typical of a second-degree injury.
III. Third degree: Disorganization of internal structure of the
funiculi, minor perineurium changes, irregular regeneration.
In a third-degree injury, regeneration is blocked by disorgani-
zation of the Schwanns cell tubes. As soon as it is evident
that recovery is slowed or absent (Tinels sign along nerve
route), exploration is considered. Distal tingling on percus-
sion over a nerve marks the most distal point of regenerat-
ing sensory axons. This is very useful in mapping nerve
regeneration.
IV. Fourth degree: Axonal rupture, funicular and perineural dis-
ruption. The nerve trunk is intact, but nerve bundles are dis-
organized. Spontaneous functional recovery is rare.
V. Fifth degree: Loss of continuity of the nerve trunk. Fourth-
and fifth-degree injuries may not be distinguishable unless
an open injury has revealed the nerve status. Although
motor nerve fibers are usually more susceptible to compres-
sion and are therefore the first to fail and the last to recover,
this is not always true. Most compression neuropathies
recover by the sixth month; when they do not, intraneural
fibrosis and disorganization have occurred. Neurolysis, both
external and internal, offers some hope of improvement.
When severe third- and fourth-degree lesions are present
with no further chance of recovery, resection of the lesions
with autografting can improve the outlook, although only in
selected cases.
Entrapment neuropathies
The pathogenesis of nerve entrapment is considered to be grad-
ual constriction by anatomic structures about a nerve and its
chronic compression against a nonyielding structure. Nerve
entrapments usually give mixed motor and sensory symptoms,
the latter of which typically come relatively late. The relationship
between nerve fiber size, motor/sensory containment, and vul-
nerability to compression is uncertain. Many believe that sen-
sory fibers are more resistant to compression than motor fibers
are, but others disagree. Entrapment of a sensory or mixed nerve
results in tenderness over the entrapment point. If the compres-
sion has produced axonal interruption, Tinels sign may be elicited
at the point of compression. Electromyographic and nerve con-
duction studies can be helpful in identifying and localizing an
entrapment lesion.
Valleix phenomenon
Pain and hypersensitivity are sometimes seen proximal to a nerve
compression. Blocking the nerve at the entrapment site relieves
the proximal symptoms. It is postulated that compression can
result in proximal nerve hyperirritability. External decompres-
sion leads to the relief of symptoms, provided that intraneural
fibrosis is not established. Intraneural fibrosis is often present
Chapter 8d Nerve injuries 375
once motor denervation has occurred (as determined by atrophy
and denervation signs on electromyography). Hence, surgery
should not wait until late in the process. If intraneural fibrosis has
indeed developed, however, intraneural neurolysis under adequate
magnification can yield some symptom improvement.
Entrapment of the common peroneal nerve
The common peroneal nerve, which transmits motor innerva-
tion to the peroneal muscles and to the extensors of the foot and
ankle, is vulnerable to compression at the fibular head and neck.
An intraneural or extraneural ganglion (with or without connection
with the tibiofibular joint), an enlarged fabella, or a bone tumor in
the proximal fibula are the most common causes of compression
at this level.
The peroneus longus muscle has two heads: a superficial head
attaching to the head of the fibula and a deep head inserting at
the fibular neck, below the nerve. After subtalar motion of the
foot, the nerve slides back and forth between the two muscle
heads, potentially leading to nerve compression.
These injuries can be part of overuse syndromes. People who
wear wooden shoes, walk on hard floors extensively, or make
repeated flexion motions in their jobs may be prone to this kind
of injury.
Symptoms include pain and hypoesthesia in the lateral leg and
ankle, a weak ankle feeling, and even occasionally footdrop.
Objectively, there is a positive Tinels sign at the compression site
together with sensory deficit and peroneal weakness. In most
cases, external decompression gives relief. Intraneural neurolysis
is indicated when intraneural fibrosis is present. It should be noted
that the peroneus longus muscle is a powerful plantar flexor of the
first ray; it maintains the medial longitudinal arch of the foot
and is an important subtalar evertor. Weakness of this muscle
leads to an altered distribution of the load on the foot when
standing; more load must be borne by the second and third
metatarsal heads, with potential metatarsalgia following.
The lateral cutaneous nerve of the calf and the sural commu-
nicating nerve, both sensory, emerge in the popliteal region from
the common peroneal nerve. Compression at this level leads to
pain on the lateral side of the lower leg, and/or dorsolateral foot.
Local anesthesia blocks at the maximum point of tenderness usu-
ally relieve the pain permanently.
Entrapment of the superficial peroneal nerve
From the division of the common peroneal nerve high in the
lower leg, this strictly sensory nerve travels between the anterior
intermuscular septum and the fascia of the lateral compartment
and emerges one or two nerves through the fascia at the junction
between the middle and distal third of the lower leg. It runs sub-
cutaneously in front of the lateral malleolus to innervate the major
part of the dorsum of the foot. The anatomy of the terminating
branches varies greatly, and they are at risk in surgery around the
first metatarsal head. Transverse skin incisions on the dorsum of
the foot should be avoided.
The nerve can be trapped where it pierces the fascia. Recurrent
ankle sprains, causing stretching of the nerve, predispose to this
condition. Pain located over the lateral aspect of the calf and
ankle and in the dorsolateral foot can be exacerbated by inver-
sion and plantar flexion of the ankle. Objectively, local tender-
ness and a positive Tinels sign are present. Three to 5 ml of a
local anesthetic relieves the symptoms, sometimes permanently,
and perineural cortisone may be tried as an additional nonoper-
ative measure, but occasionally pain recurs and requires surgical
decompression.
10
Peripheral branches on the dorsum of the foot may be com-
pressed by tight shoes such as ski boots, cicatrix, or tarsometatarsal
joint osteophytes, and produce entrapment symptoms. In these
cases, preventive appropriate shoe correction is mandatory.
Treatment with local anesthetics and sometimes a local cortisone
injection is usually successful. Occasionally, decompressive sur-
gery, including osteophyte removal, is necessary.
Entrapment of the deep peroneal nerve
The deep peroneal nerve runs together with the anterior tibial
artery on the anterior aspect of the ankle, beneath the extensor
retinaculum, and then between the extensor hallucis longus and
the extensor digitorum longus tendons to the dorsum of the foot.
A motor branch runs laterally on the mid-dorsum of the foot to
the extensor digitorum brevis muscle, terminating with sensory
innervation of the first dorsal web space. Compression between
the fascia and adjacent skeleton (osteophytes from the medial
tarsometatarsal joint) leads to pain over the dorsum of the foot
with occasional radiation into the first web space, where local
tenderness also is present. Tinels sign is sometimes positive,
and hypoesthesia in the first dorsal web space may be present.
During treatment, tight shoes must be avoided at least temporar-
ily. Surgical removal of osteophytes may be necessary, with care
taken to not injure the nerve.
2
Entrapment of the posterior tibial nerve
and branches
A mixed motor and sensory nerve, the posterior tibial nerve runs
together with the posterior tibial artery behind the flexor digito-
rum longus tendons in the distal third of the lower leg. Covered
by the flexor retinaculum, it then courses behind and below the
medial malleolus. At this point, the posterior tibial nerve gives
rise to the medial calcaneal nerve, a sensory branch that pierces
the flexor retinaculum together with a small artery, runs directly
under the posterior calcaneal tubercle, and innervates the skin of
the heel pad. This nerve may be involved in heel pain syndrome.
The tibialis posterior nerve divides beneath the flexor retinaculum
to form the medial plantar nerve and the lateral plantar nerve,
which correspond respectively to the median and ulnar nerves of
the hand. The medial plantar nerve runs under the anterior part
of the calcaneal tuberosity; gives motor branches to the abductor
hallucis, flexor hallucis brevis, flexor digitorum brevis, and lum-
brical muscles; and provides sensation to the medial part of the
sole, including the medial 3
1
/
2
digits. The lateral plantar nerve
also runs down along the medioplantar aspect of the calcaneal
tuberosity along its course to the lateral part of the plantar pedis
and the lateral 1
1
/
2
digits. Motor branches run to the adductor
hallucis muscle, the interossei, and the small muscles on the
lateral aspect of the foot.
Although entrapment of the posterior tibial nerve at the
level of the knee or lower leg is rare, it is frequent within the
fibroosseous tunnel behind and distal to the medial malleolus,
where it is referred to as tarsal tunnel syndrome. This syndrome
is characterized by burning pain on the sole of the foot, often
accentuated by ambulation but characteristically also annoying
at night. Predisposing factors include chronic instability and/or
edema, hyperpronation, and a posterior bony prominence of the
talus. Motor deficits and intrinsic muscle paresis/paralysis typi-
cally come late. Tarsal tunnel syndrome is positively correlated
with pregnancy, as is carpal tunnel syndrome, with which this
condition has many similarities. Objectively, a positive Tinels
sign is usually present together with numbness of the sole and
tenderness behind and below the medial malleolus. Delayed
nerve conduction of the medial and lateral plantar nerves further
supports the diagnosis.
The treatment of choice is surgical decompression, which
involves dividing the flexor retinaculum and freeing the nerve
proximally and distally. Internal neurolysis is indicated if the
nerve is fibrotic. If it is symptomatic by causing compression of
the nerve, occasionally an os trigonum is removed.
Joggers foot
Entrapment of the medial and/or lateral plantar nerves is occa-
sionally seen as they pass under the abductor hallucis muscle.
Joggers foot is a medial plantar neuropraxia causing burning
heel pain, aching arch, and loss of sensation on the sole of the
foot behind the great toe. The entrapment site is typically the
point where the abductor hallucis crosses the navicular tubercle.
Anesthetic blocks, steroids, and antivalgus orthotics are initial
treatment modalities, with surgical decompression sometimes
indicated.
Mortons neuroma
The plantar interdigital nerves are terminal branches of the medial
and lateral plantar nerves. Mortons neuroma is currently believed
by most investigators to be the reaction of a plantar interdigital
nerve compression. The condition is characterized by metatarsal
pain, often poorly localized but at times clearly radiating into
the toes (usually the third and fourth but possibly any or all).
Pain is aggravated by ambulation and by tight shoes. With dor-
siflexion of the metatarsophalangeal (MTP) joints, the plantar
interdigital nerves and vessels are angulated over the leading
edge of the transverse metatarsal ligament at or just proximal to
the bifurcation of the nerve to two adjacent toes. Irritation to the
nerve results in pseudotumor formation. The third-space plantar
nerve is formed from both the medial and lateral plantar nerves,
which possibly explains why this nerve is larger and more fixed
than the other interdigital nerves and therefore more prone to
compression. Other factors predisposing to this condition include
cavus foot, high-heeled shoes, and weakness of the intrinsic and
peroneal muscles.
Treatment consists of shoe correction to diminish pressure on
the metatarsal heads. In reducing MTP motion, a metatarsal bar
is often helpful. The bar should be placed posterior to (not at the
level of) the metatarsal heads and preferably between the two
soles of the shoe. The shoe also should have a wide toe box and
a low heel. A metatarsal pad set just behind the point of tender-
ness may be a successful alternative. NSAIDs and local steroid
injections are advocated by some investigators. Foot exercises
meant to strengthen the intrinsic, the peroneus longus, and the
tibial posterior are recommended. In refractory cases, surgical
removal of the compressed part of the plantar interdigital nerve
is warranted, usually through a dorsal longitudinal approach,
although some prefer a transverse plantar incision near the MTP
joint crease. Surgery usually yields a 75% to 80% rate of good or
excellent results. If secondary surgery is attempted, a longitudinal
plantar approach is recommended by most authors to achieve the
necessary more extensive exposure.
Entrapment of the sural nerve
Entrapment of the sural nerve can occur anywhere along its
course from the popliteal fossa to the toes. Purely sensory, the
sural nerve arises from the tibial nerve 3 cm above the knee joint,
runs deep to the deep fascia of the calf to the distal third of the
lower leg where it becomes superficial, runs behind the lateral
malleolus, and innervates the lateral aspect of the sole. The nerve
is often sacrificed when used for nerve grafting with minor or
no subjective problems thereafter. Inadvertent traumatization,
however, could cause annoying discomfort.
Conditions that may include local sural nerve compression
include Achilles tendon peritendinitis, recurrent ankle sprains,
lateral calcaneal or subtalar joint problems, and fractures of the
base of the fifth metatarsal. Symptoms include shooting pain
and paresthesias along the course of the nerve. Local tenderness
and a positive Tinels sign are characteristic. Occasionally, numb-
ness is noted.
Nonoperative treatment includes avoidance of external nerve
compression as well as NSAIDs and occasionally a local block.
If these measures fail, surgical decompression is advised.
Entrapment of the saphenous nerve
At foot and ankle level, entrapment of the exclusively sensory
saphenous nerve is rare. This nerve crosses over the tibia in a pos-
teromedial to anterior direction 5-7 cm above the ankle joint
and together with the greater saphenous vein runs anterior to the
medial malleolus. It innervates the proximal medial part of the
dorsum of the foot.
Depending on the nerve involved and the type of surgery
performed, return to work varies. If decompression is carried out,
the patient can return to work after a couple of weeks, even to a
job that requires walking. Surgery that involves excision or exten-
sive release may require longer recovery, and return to work is
then possible in 2-4 months.
MIDFOOT INJURIES
Midtarsal sprains
The midtarsal or transverse tarsal joint, often called Choparts
joint, that is, the talonavicular and calcaneocuboid joints, holds
a key position in the medial and lateral longitudinal arches. It also
acts together with the subtalar joints in inversion and eversion.
Midtarsal sprains are potentially disabling injuries, with healing
times often much longer than anticipated. In general, substantial
force is required to cause significant injury to these joints, for
example, when the front foot is caught and the person falls and
twists them.
A comprehensive classification system has been developed
that ranges from nondisplaced ligamentous injuries, through
subluxations, to dislocations. Fractures of adjacent bones may
or may not be present. Soft tissue engagement can be significant.
Chapter 8d Midfoot injuries 377
In addition to plain radiographs, CTs, including three-dimensional
reconstructions, or MRIs are most helpful in delineating the
extent of severe injuries in this region. Undisplaced injuries are
normally treated nonsurgically. Because of potential instability,
6 weeks in a nonweight-bearing cast followed by 2 weeks in a
walking cast is recommended. During rehabilitation, a shoe with
a firm sole and a longitudinal arch support should be worn.
Displaced fractures, subluxations, and dislocations all need to be
reduced. Occasionally, closed reduction is successful, but usually
open means are required. Internal fixation is performed followed
by restricted weight-bearing casting for 3-6 weeks.
The prognosis after midtarsal injuries is highly dependent
on whether reduction is achieved. Nonreduced injuries and
extensively comminuted fractures often do poorly. In these cases
a future arthrodesis, with prolonged time back to work, must be
considered.
Tarsometatarsal injuries (Lisfrancs joint)
The second metatarsal base is the primary bony stabilizer of the
tarsometatarsal articulation, sitting in a tight mortise between the
distal parts of the first and third cuneiforms. The cuneiforms and
the metatarsal bases are wedge shaped, being wider dorsally, and
thereby contribute to the metatarsal transverse arch. Motion in
the joints is restricted, but together they allow some pronation
and supination of the forefoot. Severe trauma to Lisfrancs joint
caused by direct or indirect forces on the midfoot can result in a
varying pattern of fractures and dislocations. Indirect forces
along the metatarsals may result in dislocation of the joint, with
or without fractures through the plantar aspect of the metatarsal
base. After fracture-dislocation of the Lisfranc joint complex,
soft tissue injuries are often extensive, and because these tissues
would be further compromised, tourniquet should be avoided.
Injuries to Lisfrancs joint are notorious for missed initial
diagnosis and inadequate treatment. The most constant reliable
radiographic sign is a slight widening between the bases of the
first and second metatarsals, between the second and third
metatarsals, or between either of the cuneiforms. Fractured frag-
ments should be sought between the first and second metatarsal
bases and between the medial and middle cuneiforms. For
adequate descriptions of radiographic findings, oblique views
are necessary.
The goal of treatment is a stable anatomic reduction. Because
of interposing soft tissues or fractured fragments, reduction is
rarely successful by closed means. Open reduction/internal fixa-
tion is recommended; transfixion is accomplished with Steinmann
pins or Kirschner wires (note that a standard Kirschner wire alone
will not hold the first metatarsal rigidly enough) or by using
appropriate screws as temporary (16 weeks) internal fixation.
Postoperatively, partial weight bearing for 6 weeks is recom-
mended, followed by a walking cast for 4 to 6 weeks thereafter.
Combinations with lower leg, calcaneal, or ankle fractures are
common, and, most importantly, the risk of compartment syn-
drome is substantial. Intracompartmental pressure measure-
ments are mandatory, and when indicated fasciotomy should be
performed without delay. Provided that the injury is closed and
reduction/fixation is adequate, the prognosis is good. If good
primary reduction is achieved, later degenerative arthritis may
occur but is surprisingly benign and nonsymptomatic. However,
open injuries and inadequate reduction most often lead to unsat-
isfactory end results.
MTP sprains and dislocations
Repetitive hyperextension loads on the first MTP joint predis-
poses to injury on the plantar aspect of the capsule around it.
Alternatively, the dorsal aspect of the joint is sprained after a
hyperflexion event. The clinical picture consists of local pain,
tenderness, and swelling. In grade III injuries, stability is com-
promised, and osteochondral damage is occasionally seen.
Treatment of MTP sprains is normally nonoperative.
Ice, compression, and elevation are used acutely. Initial immobi-
lization is required with weight bearing as tolerated, but even
then the recovery time is often longer than 10 weeks. Whereas
NSAIDs are beneficial for pain control, injections of local
anesthetics or steroids are potentially aggravating to the injury
and should be avoided. A plantar orthosis (steel or Orthoplast)
limiting dorsiflexion of the first MTP joint is used during
rehabilitation. Surgical capsule repair and removal of loose
bodies is only occasionally indicated. Strenuous activities such
as running and jumping are resumed only after the patient
is asymptomatic.
Forced hyperextension of the MTP joints beyond physiologic
limits may lead to rupture of the plantar plate either through the
sesamoids as fractures or proximally. The latter is irreducible
because of blocking from the plantar plate. Reduction is
performed with a transverse plantar incision over the prominent
metatarsal head. Great care must be taken not to sever the plan-
tar digital nerves. The dislocation is reduced by grabbing the torn
end of the plantar plate and manually relocating the phalanx to
its normal position. Once reduced, the joint is usually stable.
Postoperatively, a cast is worn for 4 weeks with weight bearing as
tolerated. Dislocations with sesamoid fractures are usually read-
ily reducible by closed means.
MTP joint dislocations of the lesser toes can typically be
reduced by closed means. Once reduced, the joint is usually
stable, and crossover taping is sufficient.
Metatarsal fractures
Soft tissue coverage of the dorsum of the foot is thin, vulnerable,
and suboptimally supplied with blood. Strong ligamentous con-
nections are present between the metatarsal necks distally and
strong bands between the bases except the first and second, where
the soft tissue connection is located between the second base and
medial cuneiform.
Common in industry, the injury often results from a direct blow
to the dorsum of the foot caused by a heavy object. Shoes with
steel-reinforced toe boxes protect the toes but not the metatarsals.
Direct force on the metatarsals usually results in transverse neck
fractures of the second, third, and/or fourth, whereas indirect force
leads to spiral shaft fractures. The common plantar flexion-inversion
trauma results in a fifth metatarsal base fracture. After severe
injuries to the midfoot, compartment pressures in the foot should
be carefully monitored and fasciotomy performed when indicated.
Treatment of nondisplaced fractures affecting the lesser
metatarsals includes the use of a firm metatarsal pad, circumfer-
ential taping, and a firm boot with a crepe sole. Undisplaced
fractures through the first metatarsal require a carefully molded
nonweight-bearing short leg cast for 2 weeks followed by pro-
gressive weight bearing as soon as tolerated.
In the treatment of displaced fractures, sagittal-plane displace-
ment inevitably leads to altered weight distribution across the fore-
foot and should be avoided. Normally, the load on the first
metatarsal head is twice that of any of the others (including the
fifth), and moderate frontal-plane displacements are not as critical.
Displaced first metatarsal fractures are best treated with open
reduction and internal fixation. Chinese woven wire traps can be
used to distract the hallux longitudinally and aid reduction. An
elastic bandage around the ankle can be used for countertraction.
It is crucial to regain length. The metatarsal is then temporarily
transversely transfixed to the second ray. If possible, rigid inter-
nal fixation is used; if not, multiple pins are used to secure the
fractures. If the fracture is open and major soft tissue problems
are present, wound care is possible only through the use of exter-
nal fixation of the fracture.
With only one displaced metatarsal fracture, closed reduc-
tion is attempted. If successful, 6 weeks of nonweight-bearing
casting follows. With multiple fractures, surgical fixation using
either screws and plates or intramedullary retrograde pinning is rec-
ommended. Casting is unnecessary after stable internal fixation.
With fractures through the metatarsal neck, closed reduction
is virtually impossible, and fixation with Kirschner wire is com-
monly used.
Work that involves much walking after midtarsal injuries may
often require a long recovery time. These injuries are often either
missed or contribute to secondary problems, and a treatment
time of 3-6 months is frequently required. It is of greatest impor-
tance to secure a correct diagnosis early to provide optimal treat-
ment and facilitate early return to work.
FOREFOOT PROBLEMS
Hallux rigidus
Hallux rigidus is stiffness of the hallucal MTP articulation,
usually secondary to arthrosis of the joint. The etiology can be
(1) juvenile hallux rigidus secondary to osteochondritis dissecans
of the first metatarsal head in some cases; (2) gout, especially in
bilateral hallux rigidus in men; (3) posttraumatic arthrosis of the
joint; and, (4) most commonly, idiopathic arthrosis of the joint,
primarily in middle-aged women, with or without the presence
of a hallux valgus. Radiographs reveal a crown of osteophytes on
the dorsal part of the metatarsal head and around the proximal
part of the proximal phalanx. Local pain and tenderness with a
varying degree of ROM restriction is clinically evident.
Treatment is initially nonoperative: rest, ice, NSAIDs, and
shoes with stiff rocker-bottom soles. Steroid injections are often
beneficial. In contrast to a true metatarsal bar, the metatarsal
rocker bar is curved rather than flat. It should never be put prox-
imal to the MTP level because it would then only accentuate the
bending of the sole. A combination with moderate heel eleva-
tion is often beneficial to rocker-bottom sole function.
Persistent pain when pushing off is a problem for many
patients, who therefore ask for surgery. A number of surgical pro-
cedures are available to treat hallux rigidus including: removal of
osteochondrotic loose bodies, removal of osteophytes, wedge
osteotomies, Keller procedure, arthrodesis, and Silastic implants.
For very demanding patients, however, arthrodesis is often pre-
ferred and is the treatment of choice today. The Keller procedure
(extirpation of the base of the proximal phalanx) potentially
results in a short unstable great toe that would impair push-off
ability. Silastic implants are contraindicated because of synovitis
and even implant breakage after strenuous loading. Other interpo-
sition arthroplasties are currently evaluated in clinical studies.
Because to date there is no optimal treatment for every patient
with hallux rigidus, individual solutions must be sought.
After surgery with arthrodesis, return to a desk job is often
possible within a week. Return to work that involves walking
requires 3 to 6 months of healing and rehabilitation.
Hallux valgus
Patients with hallux valgus and bunions invariably have prona-
tion deformities causing lateral pressure on the hallux. As it is
forced laterally, the medial portion of the first metatarsal head is
uncovered and forms most of the dorsomedially directed bunion.
The extensor hallucis longus tendon pull is displaced laterally,
further accentuating the hallux valgus deformity. The incidence
of hallux valgus is much greater in women than in men, probably
partly because of the use of high-heeled and pointed-toe shoes.
Patients seek help because of recurrent pain/tenderness over the
bunion or because of cosmetic problems and difficulties in find-
ing appropriate shoes. Objectively, both the longitudinal and the
transverse arches are insufficient. A very broad splayfoot is some-
times seen. The bursa over the bunion may be intensely inflamed:
red, hot, swollen, and very tender. The great toe is angled later-
ally and may even be overriding or underriding the second and
third toes. A hammer toe deformity of one or more of the lesser
toes is often present.
In most patients, management of hallux valgus is nonsurgical.
Orthotics correcting arch insufficiency are most beneficial, and
shoe modifications are in order. It is crucial to relieve pressure on
the bunion; a ring-shaped pad around it is sometimes helpful.
Indications for surgery can vary and include a valgus angle of
more than 15 degrees, toes lying on top of each other, recurrent
painful bursitis, painful calluses, or inability to wear shoes. A great
number of surgical procedures address bunion and the angular
deformity.
After surgery, return to work depends on the technique used.
After a simple bunionectomy, it is possible to return to work
within 4 to 6 weeks. If an osteotomy is carried out, return to
walking work is not possible until a healing time of 3-5 months
has elapsed.
Hammer toes
Characterized by hyperflexion of the proximal interphalangeal
joints, hammer toes may develop secondary to collapse of the
transverse arch of the forefoot. Painful corns on the dorsum of
Chapter 8d Forefoot problems 379
the proximal interphalangeal joints develop. If joint range of
motion is unaffected, conservative treatment is advocated,
including an arch-correcting orthotic, adequately roomy shoes,
possibly toe manipulation to maintain mobility, and strapping
of the toe in extension.
If the toes are hyperflexed and restrict walking or if major
corns and callosities are causing pain, surgery is indicated. With
established flexion contracture of the proximal interphalangeal
joint, excision of the distal end of the proximal phalanx is often
gratifying. In early stages when flexion contracture is redressable,
a flexor tendon tenotomy through a minimal incision under
local anesthesia usually is enough and requires no or minimal
postoperative recovery. Return to work is often possible 1 month
after hammer toe surgery.
The sesamoids
The sesamoids are two bones located on the plantar aspect of the
hallucal MTP joint. The medial sesamoid is somewhat larger and
bears more of the load, whereas the lateral sesamoid lies toward
the first web space. From several ossification centers, the sesamoids
ossify in early childhood. Partition is common, however, with 10%
of the population having bipartite sesamoids (unilateral in 75%
of those but bilateral in 25%; 15% having an interphalangeal
sesamoid as well). The sesamoids have articular facets located
superiorly toward the metatarsal head. The facets are enclosed in
the joint capsule, and the remainder of the sesamoids is embed-
ded in the flexor hallucis brevis tendons. The flexor hallucis
longus tendon passes between the sesamoids.
Injury mechanisms result from a direct blow caused by a fall
from a height, typically resulting in a comminuted fracture, or
forced hyperextension of the hallux leading to avulsion (transverse)
fractures of the sesamoid. Such patients typically have a dislo-
cated first MTP joint. Stress fractures are increasingly common,
specifically in competitive athletes involved primarily in running
or dancing. It is often very difficult to distinguish a stress fracture
from a bipartite sesamoid. Radiographs (anteroposterior, lateral,
and axial tangentials of the sesamoids, not the entire foot) may
show smooth or irregular edges. A stress fracture is often unde-
tectable on initial plain x-ray films. A bone scan shows increased
uptake in stress fractures but possibly also in sesamoiditis. To fur-
ther complicate the picture, osteochondral lesions of the sesamoid
have been described also.
As opposed to sesamoid fractures resulting from a single trau-
matic event, sesamoid stress fractures seem to have poor healing
potential. The fracture will not heal despite 6 weeks of casting
and months of activity restriction. Excision is recommended, with
potentially good results. Successful surgery, however, requires very
careful technique to avoid the introduction of disabling complica-
tions such as neuromas, hallux valgus/varus, or cock-up deformity.
Metatarsalgia
Metatarsalgia, or pain in the MTP region, is a condition with
many possible causes. Hallux rigidus, sesamoiditis, stress fractures,
and Mortons neuralgia are discussed elsewhere in this chapter.
A common predisposing factor to metatarsalgia is altered forefoot
biomechanics, extrinsic or intrinsic, caused by the following:
High-heeled shoes, which significantly alter the load from the

hindfoot to the MTP region;
Equinus foot, especially when caused by a tight heel cord

and/or anterior impingement of the ankle, thereby preventing
ankle dorsiflexion;
Cavus foot, where support is maintained only by the metatarsal

heads and the heel (and not also by the lateral longitudinal
arch), resulting in overload of the forefoot;
Irregular distribution of load between the metatarsal heads. In

the static standing position, all metatarsal heads bear load, the
first metatarsal head bearing double the load of the others. In
the dynamic take-off phase of walking and running, this rela-
tive first ray overload is even more evident. A disturbance of
this load distribution between the metatarsals may be caused
by an abnormally short or hypermobile first ray or by a long
second metatarsal. With a hypermobile first metatarsal, a signif-
icant part of the load is transferred to the second and third rays.
In most cases, treatment is conservative. Supporting orthotics
that relieve the overload on the metatarsal heads are often
beneficial. With a hypermobile first ray, a pad is tried just proxi-
mal to the second and third metatarsal heads and/or underneath
the first ray. Stretching a tight heel cord is essential. If significant
discomfort persists in spite of adequate orthotics and flexibility
treatment over a 6-month period, surgery must be considered.
Here soft tissue and skeletal corrections may be indicated.
Capsulitis of the second MTP joint is related to hallux valgus,
a condition in which the hallux forces the second toe to sublux
dorsally. Tenderness over the dorsal capsule and pain on passive
dorsiflexion of the second MTP joint is diagnostic. Typically, no
interdigital pain or tenderness is present. Strapping of the second
toe in a reduced plantar-flexed position is usually helpful. Rarely
an extensor tenotomy, with or without capsulotomy, is required.
SKIN CONDITIONS
Corns
Soft corns are interdigital clavi formed between toes as a result
of pressure between adjacent phalangeal condyles. Hard corns
represent accumulations of keratin layers of skin, typically on the
dorsum of the toes, to prevent ulceration of the skin from chronic
pressure that is usually extrinsic. Relief of this pressure is the key
to successful treatment. The corn should be softened and pared
judiciously. Occasionally, surgical removal of intrinsic pressure is
necessary, for example, with a prominent phalangeal condyle, a
hammer toe, or a hallux valgus.
Calluses
Calluses are hyperkeratotic lesions similar to corns that form on
the plantar aspect of the foot after weight-bearing and shearing
forces. Typical lesion areas are under the metatarsal heads and
under the heel. Underlying structural deformities such as an
insufficient transverse arch, forefoot varus or valgus, a plantar-
flexed first ray, or a long second ray are common. Local treatment
of calluses equals that of corns; custom-made orthotics are gener-
ally needed. If these measures prove insufficient, a rare event, sur-
gical correction of an underlying deformity must be considered.
The diagnosis of a cutaneous lesion is sometimes difficult.
Scar formation, warts, inclusion cysts, and foreign body inclu-
sions all may have the appearance of a corn or a callus. A careful
history, clinical examination, and occasionally soft tissue radio-
graphs are needed. In doubtful cases, referral to a highly special-
ized institution without touching the lesion is indicated.
Warts (Verrucae vulgares)
A wart is the result of a papillomavirus infection that is transferred
between individuals in showers, saunas, and locker room floors.
The incubation period is 1-6 months. Typically located on the
sole of the foot, the warts are round or oval and gray-white, have a
crack or a dark spot in the center, and are often tender to pressure.
They are commonly multiple.
Primary plantar wart treatment consists of weekly paring and
application of keratolytics (including 50% trichloroacetatic acid or
40% salicylic acid). Failure of this treatment to eradicate the wart
may warrant the use of careful electrosurgery after infiltration of
local anesthetic with epinephrine. We advise against excision of
a wart by scalpel or curet because of the risk of scar formation
from inadvertent penetration of the basilar layer of the skin.
When all else fails, x-ray therapy may be considered provided that
it is given by an experienced operator. Prevention is crucial, and
the use of bath shoes in humid areas is strongly recommended.
Blisters
Blisters result from shearing irritation of the skin typically caused
by the improper fitting of shoes and/or socks. The epidermal
layers split, and the cavity formed is filled with a clear fluid.
Treatment consists of prompt removal of extrinsic irritant and if
needed, clean aspiration of the fluid. Deroofing the blister should
be avoided because the overlying skin is a good dressing and
helps prevent secondary infection.
Fungal infections (Tinea pedis)
Occasionally referred to as athletes foot, fungal infections may
develop in circumstances where foot hygiene is inadequate. The
most common infecting organisms are Trichophyton rubrum and
Trichophyton mentagrophytes. Tinea pedis exists in both dry and
wet varieties. Predominant sites of infection are the web spaces.
The dry form appears as gray-white scaling of the skin, whereas
in the wet vesicular form, the web space skin has a macerated
appearance. Diagnosis can be made by revealing hyphae and
mycelia by light microscopic examination of scrapings from scaling
and vesicle walls.
Treatment of the dry form of tinea pedis consists of local anti-
fungal spray, whereas the wet form is best treated with potassium
permanganate or silver nitrate. A secondary bacterial infection
may necessitate erythromycin administration. Prevention such as
good foot hygiene, including frequent change of socks; shoes
allowing adequate aeration; and avoidance of barefoot walking
in locker rooms is essential.
NAILS
Ingrown toenails
Ingrown toenails are common and potentially disabling.
Posttraumatic nail deformation caused by injury of the nail matrix
may elicit the problem. The shape of toenails is congenitally dif-
ferent, with some types being flatter whereas others are folded.
Frequently, the lateral and medial edges of a folded toenail con-
flict with the adjacent nail. The problem grows when external
pressure is increased from a tight sock or a shoe with a narrow
toe box. If the edge of the nail penetrates the skin, bacterial
infection and voluminous granulation tissue result. The condi-
tion, which is most painful, typically engages the lateral aspect of
the great toe, but any toe could be affected.
Prevention is essential and includes good foot hygiene, properly
fitting footwear, and appropriate nail trimming habits. Once a week
the nails should be cut transversely because they may grow down
into the nail fold if cut to a rounded outline. Once established, the
acute-phase infection should be drained and the area soaked in
an antiseptic solution followed by a dry cover. Surgery should be
avoided in the acute phase because of the high risk of postopera-
tive infection, including potential osteomyelitis. In chronic cases,
the ingrown part of the nail, including the nail matrix of that part,
should be surgically removed. At least 3 weeks should be allowed
for healing postoperatively.
After surgery for ingrown toenails, return to work is possible
in 3-6 weeks. These conditions are painful.
Subungual hematomas (Black nail, Tennis
toe, Soccer toe)
Bleeding of the nail bed can be the result of a direct blow to the
nail from being trodden on or from a toe box that is too narrow.
The hematoma shines through the nail and renders it black or
dark blue. The condition may be very painful in the acute stage.
The hematoma is evacuated through a small hole through the
nail made with a red-hot straightened paper clip or similar tool.
Most often painless, the procedure gives immediate relief and
preserves the nail, which would otherwise fall off after 2-4 weeks
because of disruption of its blood supply.
Subungual exostosis
As a result of repetitive direct blows such as a basketball players
forefoot repeatedly being trod upon, reactive exostosis formation
may develop on the dorsal aspect of the outer phalanx of the toe
underlying the nail. Intense tenderness prompts treatment, typi-
cally nail removal and occasionally removal of the exostosis as well.
Chapter 8d Nails 381
Fissures
Very painful and most disabling, fissures of the weight-bearing
area of the sole are correlated mainly with hyperkeratosis but are
seen also in conjunction with psoriasis, fungal infection, obesity,
and shoes without counters. Hyperkeratosis-related fissures are
treated with topically applied salicylic acid. Steroid ointments or
creams might be added for a limited time. A concomitant fungal
infection may need oral antifungal treatment.
Fungal nail infections
Fungal infections of nails respond to oral antifungal treatment
only. Treatment typically must extend beyond 3 months. Because
oral antifungal drugs may be liver toxic, liver function needs to
be monitored. In some instances it may be reasonable to refrain
from treatment.
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3. Brostrm L: Sprained ankles. V. Treatment and prognosis in recent ligament ruptures.
Acta Chir Scand 132:537-550, 1966.
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11(5):349-353, 1983.
5. Kannus P, Renstrm P: Treatment for acute tears of the lateral ligaments of the ankle.
6. Komprda J: Le syndrome du sinus du tarse. Ann Podol 5:11-17, 1966.
7. Leach RE, Schepsis AA: Acute injury to ligaments of the ankle. In CM Evarts, ed:
Surgery of the musculoskeletal system, Vol. 4. New York, 1990, Churchill Livingstone
International, pp. 3887-3913.
8. Pettine K, Morrey B: Osteochondral fractures of the talus. J Bone Joint Surg
69B(1):89-92, 1987.
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SUGGESTED READINGS
Coughlin MJ, Mann RA: Surgery of the foot and ankle, ed 7. St. Louis, 1999, Mosby.
Greer Richardson E, ed: Orthopedic knowledge update: foot and ankle 3. Chicago, 2004,
American Academy of Orthopedic Surgeons.
Hansen ST: Functional reconstruction of the foot and ankle. Philadelphia, 2000, Lippincott
Williams & Wilkins.
Adaptation of Workers
with Foot and Ankle
Disorders to the
Workplace: Case Studies
Mooyeon Oh-Park, Dennis D. J. Kim, and Peter Sheehan
Treating injured workers is a challenging task for most clinicians,
especially given the fact that a significant number of workers may
not be able to return to work even after successful medical or sur-
gical treatment of injury. In addition, patient care is complicated
by other factors, including the level of patient motivation to
achieve full recovery, the system of compensation and disincen-
tives, and the influence of legal counsel. Despite these challenges,
clinicians are often relied on to treat functional impairment and
subsequent disabilities to achieve the goals of care for injured
workers: restoring function and timely returning to work after
successful treatment of the underlying pathology.
Although extensive information regarding the treatment of
foot and ankle pathologies is available in the literature, little has
been described about the types of measures necessary to minimize
deleterious functional impairment on return to the workplace.
C HA P T E R
8e
In this chapter, we first describe the biomechanical demands of
the foot and ankle in the workplace and specific anatomic and
physiologic deficits after foot and ankle injuries. Then we
describe how the disabilities from foot and ankle injuries may be
reduced by various adaptation processes such as ergonomic
modification, adaptation of work activity procedures, and the
appropriate utilization of footwear and orthoses.
The adaptation process begins by identifying the main deficits
of the worker that led to the impairment and subsequent disability.
Evaluation of workers consists of gait examination, range of motion
(ROM) of individual joints, manual muscle testing, propriocep-
tive sensation, and examination of footwear. It is important to
note that biomechanical derangement of the foot and ankle
inevitably influences knee, hip, and low back proximally because
the foot and ankle are the terminal parts of the closed kinetic
chain providing the base of support.
32
Clinicians therefore need
to evaluate the entire lower limb as one biomechanical unit. The
ROM of individual joints should be assessed considering the
functional demands of the specific work activities described later
in this chapter.
Footwear and orthoses play an important role in management
of foot and ankle disorders (Table 8e.1). When treating a working
population, clinicians should take work activities into considera-
tion in prescribing footwear or orthoses because certain appliances
may interfere with work activities despite providing excellent
symptom relief. Solid plastic ankle foot orthoses (AFOs), for
example, may relieve the pain of the worker with posttraumatic
ankle arthritis but greatly interferes with work activities such as
kneeling, crouching, or fast walking. In this situation, an articulated
AFO with limited ROM or a leather anklet would be a better
Table 8e.1 Clinical indications and function of footwear modifications
Type of
modification Clinical indications Simulated function Advantages and limitations
Cushion heel Limited ROM of ankle PF Simulates PF of ankle, reduces the kinetic Relatively costly
Ankle fusion, arthritis demand on ankle dorsiflexors
Beveled heel Same as cushion heel Same as cushion heel, delays initial contact Relatively inexpensive
during gait
Rocker sole Limited ROM of ankle Reduces dorsiflexion of 1
st
MTPJ, reduces Heavy, may affect balance, requires
DF pressure on metatarsal head, simulates rigid sole
Ankle fusion, arthritis DF of forefoot
Hallux rigidus/limitus
Toe spring Hallux limitus Simulates DF of forefoot Does not require additional
modification of footwear, lightweight
Rigid sole (steel shank) Pain or instability of midfoot Stabilizes the midfoot, reduces DF of 1
st
MTPJ Caution in diabetic patients, heavy
Hallux limitus
Removable rigid insole Painful instability of midfoot Stabilizes midfoot, reduces DF of 1
st
MTPJ Caution in diabetic patients, lightweight,
(carbon plate) Hallux limitus can be inserted in footwear
Heel lift Equinus deformity of forefoot Accommodates ankle equinus and forefoot equinus >
1
/
4
heel lift usually needs to be
Equinus deformity of ankle placed on the outsole of footwear,
footwear with high top design is
preferable
DF, dorsiflexion; MTPJ, metatarsophalangeal joint; PF, plantar flexion; ROM, range of motion.
option than a solid AFO because it allows a considerable amount
of motion.
Many injured workers may experience unexpected functional
impairment after resuming their work activities. Work-simulation
and work-hardening sessions incorporating the adaptation process
are often necessary to provide injured workers an opportunity to
assess their ability to return to work.
BIOMECHANICAL DEMANDS OF THE
FOOT AND ANKLE IN THE WORKPLACE
Knowledge of biomechanical demands of the foot and ankle in
the workplace enables clinicians to prepare the necessary adapta-
tions when returning injured workers to their duties.
Common work activities
Floor-to-waist lifting
Floor-to-waist lifting in full squat position requires maximum
ankle dorsiflexion and transfer of the center of body forward,
especially when lifting an object without a handle. Because workers
with lack of ankle dorsiflexion range are unable to perform full
squats, they often compensate by flexing the hip and the spine.
Because of an increased lever arm between the load and the lum-
bar spine, this lifting technique increases the demand on back
extensors. Workers need to take special precautions to maintain
lumbar lordosis as much as possible during lifting to protect their
backs from injury.
22
Carrying a load
According to one biomechanical study, carrying a load on the
side of an affected hip exerts less stress on it than carrying a load
on the contralateral side.
29
However, there are no studies available
regarding whether this same principle can be applied to patients
with foot or ankle disorders. Carrying a load on the opposite
side of injury theoretically increases the moment arm of the load
and may place additional stress on the affected ankle and foot. By
reducing the moment arm of a load, however, carrying it on the
side of injury may change the angle of weight bearing, causing
stress on the lateral side of the ankle. Workers therefore usually
find themselves using the side that produces fewer symptoms.
Kneeling
Kneeling is defined as supporting the body weight on both knees,
a position requiring nearly full ankle plantar-flexion. Workers
who lack full plantar-flexion range may compensate with hyper-
extension of the metatarsophalangeal (MTP) joints and slight ankle
plantar-flexion.
Crouching
In crouching with one knee up and one down, the worker needs
full ankle dorsiflexion in the forward limb. Without ankle dorsi-
flexion, he or she can compensate with external rotation of the
hip and eversion of the subtalar joint. The backward limb with
the knee in contact with the floor requires full plantar flexion
of the ankle; otherwise, the worker can compensate with slight
plantar flexion and MTP hyperextension.
Walking
About 10 degrees of ankle dorsiflexion with the knee in extension
is required for normal walking.
40
If a worker has limited ankle
dorsiflexion secondary to contracture or pain, the tibia cannot
advance forward during the stance phase. Compensatory motions
such as hyperextension of the knee, early heel rise, excessive
pronation of the subtalar joint, or shortened step length on the
contralateral side are therefore noted during gait.
SPECIFIC DEFICITS AFTER FOOT
AND ANKLE INJURIES
After foot or ankle injuries, workers may have impairments related
to abnormal ROM of specific joints, neurologic deficits, pain,
edema, or any combination of these problems even after initial
medical and surgical interventions. The functional impact of these
deficits is described in this section.
Abnormal ROM
Pain-free normal ROM of the ankle, subtalar, midtarsal, and first
MTP joints are prerequisites for normal function of the foot and
ankle. Limited and excessive ROM of these joints interferes with
normal gait and work activities. When excessive ROM of a certain
joint is noted during evaluation, the clinician should differentiate
the causes for excessive ROM, distinguishing a structural insta-
bility from a compensatory response for limited ROM of the other
joints. The pain associated with excessive ROM can be improved
by wearing footwear or orthoses designed for the control of exces-
sive motion.
Equinus of the ankle (limited ROM of ankle
dorsiflexion)
Equinus deformity of the ankle is a common abnormality after
foot and ankle injuries. Frequently seen also in patients with
spastic gastrocsoleus muscles from various neurologic disorders,
it has a profound effect on the entire lower limb during closed
kinetic motion. It affects proximal joints, especially driving the
knee joint into hyperextension during weight bearing, and distal
joints, as is seen with excessive pronation of the subtalar and
midtarsal joints.
6
Long-standing excess pronation leads to painful
arthrosis in these joints and may cause a rotatory stress to the
knee joint at the same time. Finally, patients may compensate for
the deformity by externally rotating their lower limbs, thus short-
ening the lever arm for the ground reaction force. This compen-
satory gait may be necessary for the patient to accommodate the
functional deficit in the workplace, although this gait deviation
may cause pain or instability of the medial knee later. In this
instance, the clinician should weigh the benefit and the poten-
tial harm of the deviation before correcting the gait.
6
To manage equinus deformities, clinicians should emphasize
preventive measures, including early weight bearing, preventive
orthoses, and physical therapy. Physical therapy should initially
be instituted under the supervision of a therapy team so the
patient can properly learn heel cord stretching exercises before
continuing them at home. The patients foot should be placed in
Chapter 8e Adaptation of workers with foot and ankle disorders to the workplace: case studies 384
neutral or slightly supinated position during this exercise to avoid
undesirable stretch of the midfoot instead of the heel cord.
To avoid its profound effect on the lower limb, equinus defor-
mity can be accommodated by a heel lift inside (up to
1
/
4-inch
heel lift) or outside (higher than
1
/
4-inch lift) the footwear.
Footwear with high-top design may accommodate a heel lift of
up to
3
/8 inch. The heel lift should be lowered gradually to avoid
development of pain in the calf or other proximal parts of the
body that can occur from abruptly changing the height.
Forefoot equinus is a deformity of the plantar-flexed forefoot
relative to the hindfoot that is often mistaken for the ankle equinus
deformity. Etiologies of the acquired forefoot equinus include pos-
terior compartment syndrome, nerve injury, or surgery. Workers
with forefoot equinus may complain of pain on the anterior
ankle or posterior knee due to compensatory dorsiflexion of the
ankle and hyperextension of the knee on weight bearing.
Because the ankle is already in maximum dorsiflexion, further
stretching of the gastrocsoleus muscle may exacerbate the ankle
and knee pain further. In this instance, a heel lift in high-top
footwear can accommodate the deformity if surgical correction is
not contemplated.
Calcaneocavus (limited ROM of ankle
plantar flexion)
A patient may develop limited ankle plantar flexion after rupture
of an Achilles tendon, after fractures of the ankle or hindfoot, or
as a neurologic sequelae.
10,28
Management of this deformity is
often much more challenging than that of equinus deformity.
Workers experience excessive knee flexion during weight bearing,
resulting in increased work demand for the knee extensors. Over
a period of time, workers may develop painful knee conditions
such as patellofemoral stress syndrome. Excessive stress on the
heel during the early stance phase of gait causes pain, callus, or
ulceration around it. High-top footwear with a silicone heel cup
is often helpful to reduce the callus formation and heel pain.
Limited ROM of ankle plantar flexion and
dorsiflexion and ankle arthrodesis
Injury or a subsequent surgical procedure such as arthrodesis may
result in marked restriction of ankle dorsiflexion and plantar flexion.
As mentioned earlier, lack of ankle motion results in marked change
in gait and may cause abnormal compensatory motions of the
adjacent joints. Clinicians should be aware of possible modifica-
tions of footwear that can compensate for lack of motion in the
ankle, which in turn can improve gait and halt abnormal com-
pensatory motions. A cushioned or beveled footwear heel, for
example, simulates plantar flexion and thus assists initial contact
and loading response of the gait. A rocker sole or a toe-spring
also can be used to correct the impaired dorsiflexion of the
ankle, thus improving the late stance phase of the gait.
Ankle ROM abnormalities are often seen after surgical interven-
tions. Ankle arthrodesis is performed for comminuted fracture,
nonunion, or posttraumatic arthritis. The general recommendation
for the ankle position for arthrodesis is neutral (90 degrees).
Postprocedure, these patients may have abnormal flexion momen-
tum of the knee when wearing footwear because most footwear
have heels at least
1
/2
-
3
/4
inches high that tilt the tibia forward.
Patients therefore need to choose footwear with lower heels to
minimize the abnormal knee flexion momentum that may cause
painful knee conditions over time. Arthrodesis of the ankle in plan-
tar flexion is not recommended because of possible development
of painful subtalar and midtarsal arthrosis later on.
9
An ankle fused
in slight plantar flexion can be accommodated with footwear with
a heel lift, although there is no study available investigating the
long-term effect of such modifications after arthrodesis.
Hallux limitus
Limited motion of the first MTP joint occurs after forefoot injury
or arthritis secondary to a collapsed medial arch. Compensatory
gait patterns such as external rotation of the entire lower limb or
lateral toe break during push-off are frequently observed among
such workers. Rocker-sole and steel-shank footwear are com-
monly recommended for workers with painful ROM of the first
MTP joint (Fig. 8e.1). This modification, however, makes the
footwear heavy and may not be appropriate for patients whose
balance is impaired by the reduced area of support. Footwear
with a toe-spring design can be used without the additional
weight of a rocker sole and usually does not affect balance.
Neurologic deficit
Weakness of ankle dorsiflexors is one of the most common neu-
rologic deficits affecting the foot and ankle. Various etiologies caus-
ing this weakness include peripheral nerve injuries, plexopathy,
lumbosacral radiculopathy, and compartment syndrome as well
as central nervous system disorders. Many workers with isolated
weakness of ankle dorsiflexors are able to return to work with proper
orthotic management even if neurologic recovery is not complete.
Ankle dorsiflexors contract eccentrically during the early
stance phase for loading of the foot and contract concentrically
during the swing phase for the leg to clear the ground. Footwear
with high-top designs and elevated heels reduce this biomechan-
ical demand of ankle dorsiflexors and minimize the need for
heavy bracing. High-top athletic footwear or boots with a
1
/2
-inch
heel lift are often sufficient for workers with minimal weakness,
Chapter 8e Specific deficits after foot and ankle injuries 385
Figure 8e.1 Rocker sole.
especially when early neurologic recovery is anticipated.
This approach, however, may cause development of a tight
heel cord over time, so workers should be educated to perform
exercises to stretch it.
For workers with significant weakness, a posterior leaf-spring
orthosis can be used inside the footwear. Posterior leaf-spring
orthosis is a good choice because it is lightweight, flexible, and
aesthetically favored by wearers. For workers with severe sensory
loss, deformity, or fluctuating edema, a conventional AFO with
a double upright and protective insole is recommended.
Workers with a combined weakness of ankle plantar flexion
and dorsiflexion generally require more restrictive orthoses. As
with workers whose ankle dorsiflexion alone is weak, footwear
with high-top design and elevated heel confines the ankle and
minimizes the need for heavy bracing. Molded ankle orthoses
such as the Arizona or Baldwin AFO are available, although they
tend to be more costly and bulky and may require footwear in a
large size. Semisolid or solid AFOs restrict ankle motion and
interfere with work activities, so clinicians should be cautious in
prescribing these restrictive orthoses for the working population.
Significant sensory loss can occur after nerve injury or neuropa-
thy from medical diseases such as diabetes mellitus. Compensation
for sensory deficit is not possible, and it is more difficult to man-
age than muscle weakness. Some workers develop neuropathic
discomfort, balance impairment due to poor proprioceptive
feedback, or ulcerations in the foot. A lightweight AFO with a wide
calf band and semirigid ankle design may provide some proprio-
ceptive input from the floor to the more proximal leg for balance.
For ulceration of the insensate foot, attentive wound care is
essential, as described in a later section.
Foot and ankle pain
Pain is a major reason that workers cannot return to work and seek
medical attention. When pain is the main deficit causing disabil-
ity, evaluation of injured workers is a challenging task. Workers
may experience persistent pain from subtle minor injuries even
after the obvious injuries are treated. This residual pain from sub-
tle injury can easily be misinterpreted as a psychologic etiology,
although workers are in fact suffering from real structural prob-
lems. Minor injuries can initiate symptoms in previously degener-
ated yet asymptomatic structures, causing etiologic confusion for
clinicians. In this section, general principles of how to approach
workers with foot pain are described. Diagnosis and surgical treat-
ment of individual pathologies are not discussed in this chapter.
Precise history taking provides clues for the nature of pain and
guides the direction of treatment. If the pain is markedly exacer-
bated by ambulation as compared with quiet standing, proper
control of the painful motion would be the main direction of
management regardless of etiologies. Application of several layers
of Unnas paste bandage and footwear with a rocker sole and
cushion heel may provide relative immobilization of the ankle in
the initial phase of the treatment. This is a useful temporary trial
before prescribing definitive orthosis for control of ankle motion.
Pain may also present during specific ROM of joints.
For example, workers with anterior impingement of the ankle
experience pain from its dorsiflexion. A heel lift and rocker sole
reduces the demand for ankle dorsiflexion and may provide
pain relief. An orthosis controlling the ankle dorsiflexion is
bulky and difficult to use in the workplace.
It is not uncommon for workers to experience pain in loca-
tions different from those of the injured structures. Patients with
hallux limitus or plantar fasciitis may develop lateral foot pain
from walking on the lateral foot to avoid weight bearing on the
painful medial side (lateralization of pain). In other cases, the
location of the discomfort may change as the disease progresses.
A patient with tibialis posterior tendon insufficiency, for example,
may develop pain on the lateral hindfoot at a later stage as the
pronation deformity progresses even though the pain was initially
on the medial side. This lateralization of pain may confuse clini-
cians attempting to diagnose and treat the primary pathology.
Edema of the lower leg
Persistent swelling of the lower leg may prevent patients from
returning to work even after initial treatment is successful. In
many instances, the edema is due to multiple factors, including
residual inflammation, venous and lymphatic insufficiency, reduced
elasticity of soft tissues, and dependent position of the legs.
33
Provided that arterial supply is not compromised, compression
treatment such as Unnas paste bandage, elastic bandaging, and
compression stockings is the mainstay of treatment.
In particular, Unnas paste bandage, a zinc oxideimpregnated
nonelastic gauze, can be used as an effective initial treatment
of edema (Fig. 8e.2). It does not yield circumferentially while the
bandage remains in contact with the skin. This causes a compres-
sion force around the leg while its contour keeps changing
with ankle motion, especially during ambulation. In so doing,
the bandage acts like the natural pump of the calf muscle in
Case: Burning pain around the medial ankle
A 45-year-old electrician in a large city hospital presented
with burning pain on the medial side of the right ankle.
Pain was more prominent when standing and was relieved
by sitting. The patient had sustained a right Achilles ten-
don rupture and subsequent surgery at the age of 22 from
a work injury and had equinus deformity of the right foot.
On physical examination, Tinels sign was present on the
medial side of the ankle. An electrodiagnostic for tarsal tun-
nel syndrome was negative. Because of the tight heel cord,
significant pronation was noted on the right side on weight
bearing. A tender point reproducing the symptom was
identified along the location of the saphenous nerve. The
patient was diagnosed as having a saphenous neuroma near
the old operation scar aggravated by pronation of the foot.
A detailed history revealed that the patient had recently
changed his working boots to low-heeled athletic
footwearthat stretched the saphenous nerve due to com-
pensatory pronation for his tight heel cord. The patients
pain wassignificantly reduced by
3
/8
-inch heel lifts placed
inside the shoes, and he subsequently returned to work
without any further intervention. The patient was
instructed to wear his old working boots or basketball
sneakers with elevated heels inside them.
mobilizing interstitial fluid.
23
The greatest advantage of the
bandage is that of allowing the worker to return to standing
activities while controlling the edema at the same time. Workers
can wear regular footwear and continue to perform physical
therapy with the bandage in place. Unnas paste bandage is also
inexpensive, readily applicable, and easily removable. During
the application, it should be cut frequently and applied evenly
in contact with the skin to avoid excessive constriction that may
result in a local purpura or skin abrasion. To maintain its effec-
tiveness, the bandage must be kept dry in the shower. As men-
tioned earlier, Unnas paste bandage should not be applied to the
patients with significant arterial insufficiency of the lower limb.
FOOTWEAR AT THE WORKPLACE
Direct injuries to the foot and ankle form a substantial proportion
of all reported occupational accidents. In addition, many injuries
to other parts of the body result from slips, trips, and falls par-
tially attributable to inappropriate footwear. Patients working in
specific occupations are obligated to wear various types of safety
shoes for protection from environmental hazards or injuries at
the workplace. The special features, advantages, and potential
problems of the safety footwear used in the workplace are
reviewed in this section. Military shoes and footwear for women
in the workplace are also described briefly.
Safety shoes
Regardless of manufacturer, most safety footwear has common
features such as a reinforced toe cap and steel plates for protection
of the plantar sole (Fig. 8e.3). Further specialized footwear is
available also to protect against cutting injuries or environmental
hazards related to chemicals, extreme temperature, or electricity.
12
Each country has different standards and methods of assessing
the level of protection against various hazards for safety shoes.
To assess the level of protection against impact to the toes, for
example, the American National Standard Institute standards
have a single pass-fail figure for all sizes of the footwear, whereas
the European standards have a sliding scale that increases with
footwear size.
Features of safety shoes
The toes are most vulnerable to injuries and also the easiest to
protect effectively with the least ergonomic penalty. Protective
toe caps are a compulsory requirement of most safety footwear
standards. For example, European standards for personal protec-
tive equipment require protection against 200 Joules for the toe
area
12
that is achieved mostly by a carbon steel toe cap. Plastic toe
caps, however, are used in environments where metal cannot be
used such as when handling munitions or inflammable chemicals.
Protection of the plantar sole against penetration injury is pro-
vided by a stainless steel plate in the outsole layer. Material that
resists penetration, strain, and corrosion is used to make a plate
large enough to cover most of the plantar surface. Although pen-
etration testing is standardized throughout the world, slight dif-
ferences exist in the minimum permitted penetration force,
which is 1100 N in Europe and 1200 N in the United States.
12
Specific outsole materials are used in specific footwear for
slip resistance. To secure the optimal effect of slip resistance,
workers need to replace the footwear on a regular basis to avoid
using worn outsoles. Currently, no method of testing is
available for the durability of slip resistance. Prevention of slip
injuries should involve measures such as educating workers,
avoiding the use of floor polish, and abrading the outsoles of
new footwear.
25
Heat insulation is a special feature of safety shoes to prevent
injury and discomfort for the workers standing on hot surfaces
such as the tar used to pave roads. The outsoles of the footwear
are produced from materials with a high melting point such as
vulcanized rubber marked with the code HI (heat insulation).
Chapter 8e Footwear at the workplace 387
Figure 8e.2 Unnas paste boot bandage.
Figure 8e.3 Safety shoes.
Potential problems of safety shoes
Wearing safety shoes may cause several problems at the expense
of protective features. One study showed that a high percentage
of workers (91%) complained of foot problems caused or exacer-
bated by safety shoes.
26
The common complaints were intolera-
ble heat, inflexible soles, shoe weight, and pressure from steel
toe caps. Workers wearing rubber boots in the meat packing or
fishing industry may develop allergic reactions to the material or
develop mycotic and bacterial lesions from plantar hyperhidrosis.
4
Clinicians should be aware of potential foot problems related to
the use of safety shoes in workers with certain medical conditions.
Patients with diabetic neuropathy, for example, may develop
ulcers on the dorsum of the toes or plantar forefoot from hard
soles and steel toe caps.
Unfortunately, there are not many choices in terms of the width
and shape of safety shoes currently available. Workers with wide
forefeet may settle for wearing larger sizes. In these instances,
excessive room around the heel may cause undesirable slipping
during ambulation. To compensate, a soft heel cup can be placed
inside the footwear to provide a snug fit.
Military shoes
Military shoes merit discussion because they can cause significant
morbidities in recruits who are expected to perform strenuous
physical feats. Recruits can develop various foot and ankle injuries
ranging from skin blisters to ligament sprains, tendonitis, and stress
fractures. Continuous efforts have been made by the researchers in
the field of military medicine to improve military shoes and
reduce such injuries.
One study of military shoes showed that three different widths
for each shoe length were necessary to accommodate the feet of
military recruits.
14
Interestingly, this study also showed that
choosing larger shoe sizes to accommodate the necessary width
when appropriate widths were unavailable did not necessarily
increase the incidence of overuse injuries.
14
To reduce overuse injuries of the foot and ankle among military
recruits, various insoles have been tried.
17,41
One study indicated
that to attenuate peak pressure during running and marching,
Sorbothane is superior to other insole materials such as viscoelas-
tic polymetric, polymetric foam, and Saran.
41
Once worn out,
these insoles lose their shock-absorbing ability,
11
but custom-
made insoles have nevertheless been reported to decrease the
incidence of stress fractures among military recruits.
13,27
Additional appliances may help prevent ankle injuries or reduce
the development of severe foot blisters. Ankle injuries are espe-
cially common during parachute training, accounting for 30% to
60% of all parachuting injuries. In one study, an ankle brace
applied outside the boots significantly reduced ankle inversion
injuries without increasing injuries to other parts of the body.
2
Foot blisters are common and can be severe enough to require
medical treatment. Knapik et al
21
reported that the incidence and
the severity of foot blisters can be reduced with dense wool-
polypropylene socks combined with polyester liner as compared
with standard military issued socks during training. Two layers of
socks probably absorb the friction better than a single layer as
this principle has been practiced in various sports activities.
Footwear for female workers
Certain professions require female workers to wear footwear
designed for the aesthetic features rather than for the health of
the foot and ankle. Womens high-heeled shoes, especially
pumps, contribute to many problematic foot disorders including
bunion formation, interdigital neuritis, metatarsalgia, hump pump,
and tight heel cords. Most of these conditions improve with
roomier footwear without extensive medical treatment.
If employees are required to wear high-heeled shoes, they
need to be educated to choose those with a proper wedge angle
to reduce anterior slippage of the foot. Pumps without proper
suspension require an extremely tight fit to prevent the foot from
slipping out. High-heeled shoes with proper closure and suspen-
sion such as straps or laces are preferable to pumps because they
do not need to fit tightly.
Another common problem women tend to develop is pain in
the calf and in other parts of the body when they have changed
abruptly from high- to low-heeled shoes, possibly due to biome-
chanical compensation for tight heel cords.
32
In such cases, a
gradual change over several months to low-heeled shoes is gener-
ally recommended for patients whose heel cords are tight.
Case: Toe blisters from wearing safety footwear
A 49-year-old man with a 10-year history of noninsulin-
dependent diabetes mellitus presented with plantar ulcer-
ation at the right hallux (Fig. 8e.4). The patient was working
as a housekeeper in a large municipal hospital. A few days
before presentation, the patient had noticed a blood stain
on his sock. He had recently changed footwear from athletic
walking sneakers to safety shoes with hard soles and steel
toe caps that had been given to him by a colleague at work.
The patient developed blisters on the plantar aspect of the
right hallux that had caused no discomfort because his
foot was insensate from diabetic neuropathy. Treatment
involved use of an Aircast walker with a thick insole and
local relief. To prevent recurrence of the ulcerations, the
patient was instructed to substitute orthopedic footwear
with soft insoles for the safety shoes. He was placed in a
job-retraining program also.
Figure 8e.4 Ulceration on the plantar aspect of hallux after wearing
safety shoes.
FOOT ORTHOSES
Foot orthoses (FOs) were introduced in the working population
not only for foot and ankle problems but also for suprapedal con-
ditions such as low back pain.
19
Although literature is available
regarding the application of FOs, there is no general consensus
about the benefits of their use by workers. Application of generic
foot insoles (orthoses) without consideration of the distinct abnor-
mal biomechanics of each patient did not show consistent benefit.
The goals of orthotic management in painful foot conditions
are pain relief, accommodation of limited ROM, and restoring
the normal alignment of the foot and ankle. Clinicians should
keep in mind that foot pain can be relieved even without com-
plete restoration of the normal alignment. Successful orthotic
treatment depends on understanding the biomechanics of the
foot and the suprapedal segment. Clinicians need to interrelate
the patients biomechanical abnormalities and the design of FOs;
they may consider trying temporary insole modifications before
prescribing definitive FOs.
Preparatory trials
If a patients discomfort improves with the preparatory trials of
an insole such as posting, padding, or heel lifting, the clinician
can feel confident that customized FOs with these features are
beneficial. Because such FOs are highly costly and not always
modifiable, clinicians should be familiar with the practice of
using preparatory trials before prescribing them. Patients wearing
FOs require regular follow-up, and depending on the material
and their activity level, the FOs need to be replaced every 3 to
6 months. Details of different types of FOs are described under
individual foot and ankle conditions below and later in this
chapter.
Pronation control
An FO for pronation control is designed to decrease rather than
completely correct pronation.
30
Because normal walking requires
a certain degree of pronation, complete correction may cause
pain in the lower limbs and back. Orthotic management for
pronation control will not be successful if tight heel cord, a
major biomechanical culprit for excessive pronation, is not
addressed. Accommodation of tight heel cord with proper heel
lift should be incorporated in the design of the selected FOs and
shoes.
Supination control
Workers with cavus foot are prone to stress fractures, heel pain,
or lateral ankle sprains. FOs are often designed to reduce ankle
inversion and to provide shock absorption. The medial arches
of the FOs are built to accommodate the high arches of cavus feet.
FOs with an excessively high medial arch, however, may increase
ankle inversion injury or cause pain on the lateral foot.
Cautiously designed arches and appropriate lateral balancing of
the FOs are necessary to minimize the sliding of the foot laterally.
ADAPTATIONS FOR COMMON CONDITIONS
Although similar principles may be applied to other types of foot
injuries, this chapter focuses on adaptation for the most common
and troublesome conditions.
Ankle sprain
As the most common foot and ankle injury, ankle sprain
accounts for more than 70% of all ankle injuries requiring
absence from work.
3
Ankle sprain is generally treated with short-
term rest, ankle bracing, and physical therapy. Edema and pain
caused by the sprain are exacerbated during standing or walking
and further delay return to work. Along with Unnas paste
bandage to control edema (the details of which are described
earlier), relative immobilization allows workers to resume standing
and walking early.
The mainstay of physical therapy after lateral ankle sprain
includes strengthening of the ankle evertors in a progressive
manner and stretching of the heel cord followed by propriocep-
tive training.
24,34
Isometric strengthening of ankle evertors can be
performed at the workplace by pushing the lateral side of the
foot against a stationary object such as the leg of a desk.
A lateral hindfoot wedge placed under the insole reduces
hindfoot inversion during the initial contact period of the gait
cycle. Although anklets, high-top shoes, or boots have been rec-
ommended as a preventive measure, their effectiveness in pre-
venting ankle sprain is controversial.
15,18,37
Because footwear with
excessively worn lateral heels increases ankle inversion, clinicians
should examine workers footwear as part of the evaluation.
Lingering pain or instability after ankle sprain should be eval-
uated for possible concurrent pathologies such as syndesmosis
lesion, pericuboidal soft tissue injuries, Lisfrancs joint injuries,
talar dome injury, peroneal tendon pathology, subtalar joint
instability, or peroneal nerve injury. Recurrent ankle sprain should
alert the clinician to look for underlying instability of the ankle or
subtalar joints, cavus deformity, weakness of the ankle evertors,
or tight heel cord.
1,8
Treatment of these conditions is beyond the
scope of this chapter.
Case: Swelling and discomfort after lateral
ankle sprain
A 43-year-old man working in a movie theater fell on the
stairs and sustained lateral ankle sprain. A radiologic study
excluded fracture or dislocation, and the patient was
treated with ice and elastic bandage in an emergency
room. Because of persistent discomfort and swelling of the
lateral ankle, especially during standing, the patient could
not return to full-time work. A short Unnas paste bandage
was applied with a horseshoe pad around the lateral malle-
olus for 3 weeks, during which time the patient returned to
full-time work with a weekly change of bandage. A lateral
wedge was placed in his walking athletic footwear to
decrease ankle inversion.
Chapter 8e Adaptations for common conditions 389
Ankle arthrosis after fracture
A major complication of ankle and pilon fractures is posttraumatic
arthrosis, which correlates with the severity of the original injury
and the adequacy of fracture reduction.
16,36
Workers with post-
traumatic arthrosis present with stiffness, pain, and difficulty with
prolonged ambulation and standing. In conjunction with footwear
that has rocker soles and cushion heels, FOs designed for limiting
the painful range of the ankle may reduce the pain significantly.
A patient with a collapsed talus after a fracture may complain
of anterior ankle pain due to anterior impingement during
dorsiflexion. In these instances, an anklet or an AFO with a heel
lift (or, alternatively, high-heeled Western boots) may reduce the
impingement and provide symptom relief. Job modification and
nonsteroidal antiinflammatory medications can provide addi-
tional benefit. Surgical treatment options are reserved for cases
refractory to conservative treatment. Total ankle arthroplasty has
been recently advocated for posttraumatic arthrosis, although its
long-term result has not been defined. This procedure should be
undertaken cautiously in the working population, which is typi-
cally young and engaged in a high level of physical activity.
Heel pain
Heel pain is a common complaint of workers engaging in activi-
ties that require prolonged standing. The etiology of heel pain can
include fat pad atrophy, heel spur bursitis, plantar fasciitis, nerve
entrapment, Haglund deformity, and calcaneal stress fracture.
Plantar fat pad atrophy, which causes pain after standing for a
period of time, is quite disabling in workers such as parking
attendants, security guards, or operating surgeons. In most patients,
the pain usually improves with a change to footwear with soft heels
and insoles. Additional cushioning can be provided by a soft
heel lift such as a silicone heel cup.
In some patients, heel pain may persist despite the above
measures because a silicone heel cup cannot prevent the fat pad
from spreading as it bears weight. In these instances, low-dye
taping can be used as an additional measure to contain the fat
pad. Plastic heel cups (Helfet) are traditionally used to prop the
heel pad. Because they are made of relatively inflexible materials,
they may cause discomfort in some patients unless a precise
fitting is achieved.
Plantar fasciitis is typically painful in the morning, although it
can be symptomatic whenever standing. Heel lifting reduces the
discomfort, most likely by reducing tension in the plantar fascia
and shifting body weight to the forefoot. The workers should
stretch the plantar fascia and heel cord several times per day.
Adequate stretching of the plantar fascia during the night fre-
quently reduces the morning pain. A night splint has been recom-
mended for this purpose, although it is bulky and cumbersome.
Gently wrapping the foot with an elastic bandage to keep the MTP
joints in dorsiflexion seems to be one of the effective alternatives.
Tibialis posterior tendon insufficiency
Patients with this condition present with an initial complaint of
pain in the medial hindfoot and progressive pronation deformities.
Because the initially flexible deformities frequently become rigid
over time, aggressive orthotic treatment with direct control of
the subtalar and midtarsal motion should be introduced in the
early stages of the condition.
35,39
A plain FO with a medial
wedge is usually not effective in this condition because it cannot
control the forefoot abduction or the motion of subtalar and
midtarsal joints effectively. Once the axis of the subtalar joint is
medially deviated as the pronation deformity progresses, a sim-
ple arch support is not able to provide any corrective force to the
pronating foot on weight bearing.
20
The University of California
Biomechanical Laboratory (UCBL) supramalleolar orthosis pro-
vides direct control of calcaneal motion, restoring proper align-
ment of the subtalar and midtarsal joints. These orthoses can be
used in regular footwear and allow the patients to continue their
work activities (Fig. 8e.5). For the more advanced cases, a short
rear-entry articulated AFO (Marazano AFO) has been advocated.
Tight heel cord, a common sequela of this condition, contributes
also to the development of permanent deformities. Orthotic man-
agement is often frustrating in patients with tight heel cord, rigid
deformity, and arthritic changes of subtalar and midtarsal joints.
Various surgical procedures are advocated for patients with an
advanced stage of the condition. If surgery is not feasible, a rigid
polypropylene AFO or Baldwin orthosis can be prescribed.
5
Bulky and restrictive, these orthoses may, however, interfere with
the activities at work.
Midfoot arthrosis and pain
The functional significance of midfoot injuries is often unrecog-
nized by practitioners.
7
Workers may sustain midfoot injuries
despite wearing standard safety shoes because the protective toe
cap ends around the MTP joints. A device available for the pro-
tection of the dorsum of the midfoot is not favored by workers
due to the restriction of motion.
12
Midfoot crush injuries with nerve damage or compartment
syndrome can prolong recovery and require as long as 1 to 2 years
before return to work is possible. Many of these patients are not
Case: Insidious onset of medial hindfoot pain
in a nurses aide
A 55-year-old woman working as a nurses aide developed
insidious onset of pain on the left medial aspect of the
hindfoot 6 months ago. She also noticed that the medial
arch of her left foot was collapsing and her forefoot was
turning progressively outward. On physical examination,
maximum tenderness was noted on the tibialis posterior
tendon, and pain was precipitated by passive eversion and
active inversion. The patient had flexible pronation defor-
mity of the left foot with a slightly tight heel cord. Passive
ROM of the ankle was up to neutral. She was diagnosed
as having stage II tibialis posterior tendon insufficiency,
and a supramalleolar orthosis was prescribed (Fig. 8e.5). The
patient was able to work wearing the supramalleolar orthosis
inside athletic footwear. A
1
/
4-inch heel lift was provided on
the contralateral side to balance the limb length bilaterally.
capable of returning to heavy-duty industrial jobs and require
vocational retraining.
1
To return to work, patients often require
rigid FOs in rocker-soled shoes to reduce the motion of the
transverse tarsal and Lisfrancs joints.
Painful forefoot conditions
Roomy footwear is the prerequisite for successful treatment of
painful forefoot conditions such as interdigital neuritis, painful
calluses, and metatarsalgia of various etiologies. Frequently used to
remedy such painful conditions, a metatarsal pad should be placed
close to the target metatarsal head.
38
According to plantar pressure
recording during ambulation, the area of peak pressure of the sec-
ond metatarsal head moves 6 to 8 mm distally from that of the
standing position (unpublished data). Placed too proximally,
therefore, a metatarsal pad may be ineffective in relieving pain.
For the plantar pain of the second MTP joint, clinicians
should look for underlying biomechanical abnormalities such as
subluxation of the second MTP joint or short first metatarsal or
first ray insufficiency. Mortons extension to the hallux or post-
ing under the first ray is incorporated into the FO in addition to
metatarsal pad that be placed next to the second metatarsal shaft.
A spring-carbon plate effectively limits the forefoot motion and
can be used in conditions such as painful hallux limitus, turf toe,
or stress fracture of the metatarsals.
Foot problems in workers
with diabetes mellitus
Complications of the foot and ankle such as Charcot neu-
roarthropathy or ulcerations in patients with diabetes mellitus
are manageable conditions without definitive cure. The important
role of the clinician is therefore prevention and early recognition
of these potentially disastrous complications and long continu-
ous follow-up. A foot that is warm and swollen after minor
trauma should alert the clinician to the possibility of early devel-
oping Charcot neuroarthropathy. Workers with a small callus
under the metatarsal head may already be harboring a full-thickness
ulceration beneath it that can lead eventually to limb loss. In
addition to treating the medical conditions, clinicians should
manage these workers with long-term plans such as major job
modification or retraining for different vocations.
Neuropathic ulceration
Neuropathic ulceration usually occurs on the plantar surface of
the foot. Off-loading plantar pressure and reducing weight bearing
are the key components of treatment. The most effective method
of off-loading, total contact casting maintains the ambulatory
state. With such a cast, the patient with superficial noninfected
ulcers may be able to return to sedentary work (see Fig. 8e.6).
Workers with insensate feet may not be able to tolerate safety
shoes with steel toe caps and hard soles because of the risk of
ulceration. Clinicians may advise such patients to consider voca-
tions that do not require safety shoes.
Charcot neuroarthropathy
Ankle and foot injuries such as fracture, dislocation, or even
minor ankle sprains in the diabetic population should be treated
with extreme alertness because of the potential risk of Charcot
neuroarthropathy, the major complication that leads to amputa-
tion of the lower limb. Beginning with intense inflammation of
soft tissues, joints, and bones, Charcot neuroarthropathy eventu-
ally results in fractures, dislocations, and gross deformities. It
may then cause an increase in plantar weight-bearing pressure
and ulceration of the insensate foot. To prevent disastrous
sequela, the patient requires a period of immobilization without
weight bearing by the injured lower limb that is much longer
than that of nondiabetic patients.
Even without a history of significant trauma, unilateral swelling
of the foot should alert the clinician to possible development of
Charcot neuroarthropathy. Redness, swelling, and warmth are
often confused with infection or cellulitis, but these diagnoses
can be eliminated if there are no constitutional symptoms or
open wound and the midfoot and hindfoot are involved.
Chapter 8e Adaptations for common conditions 391
Figure 8e.5 Supramalleolar orthosis.
Figure 8e.6 Total contact cast.
In the acute stage of Charcot neuroarthropathy, a total con-
tact cast is applied for optimal immobilization; this can be
changed to a custom-made AFO in later stages. A Charcot
restraint orthotic walker and patellar tendon bearing AFOs are
ideal to relieve weight on the lower limb, but these appliances are
cumbersome and may reduce patient compliance. An orthosis of
hybrid design, an AFO with a leather calf piece and double uprights
attached to the shoe, can be an alternative when the patient has
reached a coalescing or healing phase (Figs. 8e.7 and 8). Because
treatment of diabetic neuroarthropathy is a long, tiring process,
the patients should be educated to expect it.
Partial foot amputation
Workers with partial foot amputation frequently develop
equinovarus deformity of the residual foot due to muscle imbal-
ance between the strong plantar flexors-invertors and relatively
weak dorsiflexors-evertors. Recurrent skin breakdown occurs
mostly on the plantar aspect of lateral-distal stump. Stretching
the gastrocsoleus muscle by exercise is not feasible in most cases
due to the short lever arm of the residual foot, poor condition of
the plantar skin, and long-standing contracture of the heel cord
as well as the ankle capsules. Surgical correction of equinovarus
deformity with an Achilles tendon lengthening, Achilles teno-
tomy, or gastrocnemius recession should be implemented early.
A short high-top shoe with a molded insole and rocker sole
(stubby shoe) is a good choice to prevent recurrent ulceration of
the residual foot, although workers may dislike its unaesthetic
appearance. Workers with limited ankle ROM after partial foot
amputation may use partial foot prostheses. Orthopedic
footwear with a toe filler, steel shank, and rocker sole has been also
recommended for these patients. Such a shoe, however, is heavy,
affects the patients balance, and requires heel lift of the other shoe.
Venous and lymphatic disorders
Complications of venous insufficiency are dependent edema on
standing, recurrent ulceration of the leg, and contracture of the
heel cord. Compression therapy with Unnas paste boot or
multiplayer compression bandaging followed by the application
of compressive stockings is the mainstay of treatment for
venous insufficiency as long as patients do not have significant
Case: Persistent swelling and increased
temperature of the foot after minor injury
A 36-year-old man with a 20-year history of insulin-
dependent diabetes mellitus twisted his right ankle during
carpentry work and sustained a fracture at the right fifth
metatarsal base. In spite of treatment with a hard-soled shoe
for 3 months in another health care facility, the patient had
persistent swelling and local warmth of the foot for
12 months, a history typical of Charcot neuroarthropathy.
The patient was subsequently treated with a total contact
cast for 11 weeks until the clinical signs of the consolidation
phase appeared, followed by several months of bracing
(Figs. 8e.7 and 8e.8).
Figure 8e.7 Ankle foot orthosis with hybrid design (double uprights
with leather calf piece attached to the shoe).
Figure 8e.8 Ankle foot orthosis with hybrid design (double uprights
with leather calf piece attached to the shoe).
arterial insufficiency. Patients should be educated to apply the
compressive stockings and footwear in the morning, when edema
is less prominent. For workers engaging in physically demanding
jobs such as construction, surgical closure of the leg ulceration
should be considered early to avoid the contracture of the heel
cord that may further compromise foot and ankle function.
31
Acquired lymphedema of the lower limb may develop in the
working population due to medical or surgical conditions.
Optimal control of lymphedema can be achieved by short-stretch
bandaging combined with manual lymphatic drainage, compre-
hensive decongestive therapy, and compression stockings.
Currently, the cost of these treatment measures is a major burden.
CONCLUSION
The ultimate goals of care for workers with foot and ankle injuries
are restoring function and allowing a timely return to work.
Clinicians should be knowledgeable about the details of various
adaptation measures such as footwear and FOs with realistic
expectations and goal setting. By using present technologies
based on sound biomechanical principles, most injured workers
may be able to resume useful function and satisfactory quality of
life. Clinicians should have a long-term plan in the early stage of
management so that a major job modification or retraining can
be implemented if necessary.
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C HA P T E R
Functional Performance Testing
Michiel Reneman and Harrit Wittink
Musculoskeletal pain represents a significant burden to all sectors
of the population, with many working days lost due to back
pain and muscle/joint pain. A study
72
found that the prevalence
of arthritis, back pain, headache, and other musculoskeletal
conditions was 57% among the fully employed compared with
59% among the underemployed and with 63% among the
unemployed (p < 0.01). The cost due to lost productivity time
because of these common pain conditions to employers is an
estimated $80 billion per year. Job requirements that exceed the
workers physical abilities, a decline in physical abilities for instance
due to progressive musculoskeletal illness (such as arthritis), or
advancing age may lead to musculoskeletal impairments that
may cause a loss of function severe enough to render a worker
unable to meet the physical requirements of the job.
The National Institute for Occupational Safety and Health
report on Musculoskeletal Disorders (MSDs) and Workplace
Factors
60
examined the epidemiologic evidence for a relationship
between physical workplace factors and low back MSDs. Strong
evidence was found for the association between back disorders,
work-related lifting and forceful movements, and whole body
vibration. Evidence was found for the association between back
disorders and heavy physical work (especially in combination with
awkward postures). For neck MSDs, there is a strong evidence for
an association with high levels of static contraction, prolonged
static loads, or extreme working postures involving the neck/shoul-
der muscles. There is evidence for an association between neck
MSDs and highly repetitive work and forceful exertion.
Acute pain complaints are usually self-limiting, but if they
become chronic the consequences are serious. Musculoskeletal
impairments are the most common causes for occupational dis-
ability and loss of work. The consequences in terms of the distress
of patients and their families, for employers in terms of sickness
absence, and for society as a whole in terms of welfare benefits,
lost productivity, and health care costs are enormous. It is the
loss of function that creates disability. Disability is defined as the
inability of the individual to meet expectations normal for ones
age and gender as well as ones social and cultural environment.
57
In recent years it has been recognized that the information
about a workers medical impairment is not a valid predictor of
inability to work. Physical measurements such as tests for range
of motion and muscle strength were shown to be poorly related
to functional abilities and to have little value in predicting
disability. Self-report measures of function and disability may
be strongly influenced by psychosocial factors and are consid-
ered subjective by definition. Self-report assessments frequently
do not agree with more objective measures such as observing
the patient performing functional activities and the results of
physical examination. Medical assessment, performed by physi-
cians, of the ability to perform work-related activities is based
on a more or less standardized interview and a physical examina-
tion. A direct comparison between expert assessments and a
direct performance evaluation has not yet been performed, likely
because of the poor psychometric properties of the expert assess-
ments. From a need for a more objective measure of a persons
physical capacity for work, functional capacity evaluations (FCEs)
have been developed.
The introduction of FCEs cannot be tracked to a specific
point in time; however, the practice is regarded as originating in
the United States in the 1970s. Physicians were asked to assess
the work ability of injured patients but were unable to do so
based on a history and physical examination only. They in turn
asked physical and occupational therapists to measure the patients
ability to work. The therapists compiled existing and self-
developed tests into a battery of tests and named them FCEs.
The original definition of FCE was a systematic process of
measuring and developing an individuals capacity to depend-
ably sustain performance in response to broadly defined work
demands.
51
Over the past three decades FCEs have become big
business as judged by the more than 1 million websites available
on the Internet.
Describing FCEs and their components requires a clarification
of the terminology commonly used in this area. Since the intro-
duction of FCEs, there has been a general inconsistency in the
terms used to describe the evaluation itself, its procedures, and
results. Terms such as functional capacity evaluation, functional capac-
ity assessment, physical capacity evaluation, physical performance analy-
sis, work capacity evaluation, work tolerance screening, and functional
ability evaluation were and still are used interchangeably, in some
9
instances mistakenly.
1
The words assessment, evaluation, testing,
screening, capacity, performance, ability, functional, and physical are
used interchangeably, causing significant confusion. For clinicians
and researchers to understand each other, a common language
with clear definitions of terms is imperative (Table 9.1).
We chose to use the term functional performance evaluation
(FPE) in this chapter, realizing that the acronym FCE is more
widely known in the field. The reasoning for this is that in
its essence the FPE is an evaluation of a persons ability to
perform activities. An elaboration of the differences between
performance and capacity is presented below. Placed into
the context of work, the FPE becomes a test to measure the
individuals ability to meet or exceed the physical demands of
the work, with specific reference to a job and the tasks involved
(in turn specified into duration, load, and repetitions).
PURPOSES
The measurement of the ability of a person to perform work-
related activities can be used to serve several purposes (listed
below). They may not be used for all these purposes with every
client but should depend on the client need, referral request,
or clinical or administrative requirements. Selection of type
and components of an FPE may be guided by the purpose for
which it is used. A clear understanding from the referral source
regarding the purpose of the FPE is essential in choosing an FPE.
The purposes of FPEs are as follows
38
:
1. To determine the need for intervention and treatment, and to
design and plan treatment. The perspective here is mainly
clinical to determine whether an intervention is necessary and
to design a program to improve on those activities that have
shown to be deficient.
2. To determine an individuals ability to perform the demands
required in relation to the work context. The perspective here
is both administrative and clinical. From the administrative
viewpoint, the purpose is to ensure a safe and speedy return
to work, thereby reducing costs. From a clinical viewpoint,
the purpose is to ensure that the match or mismatch between
the individuals level of function and the work demands has
been identified to lower the risk of further injury and to
implement appropriate work modifications if necessary.
In evaluations where return to a former job is an issue, a job
analysis should be performed to determine the tasks required
for the job. A good job analysis requires a work site visit
during which, for instance, the frequency, duration, intensity,
and the distance a person must lift, bend, and reach is identi-
fied and recorded, in addition to other factors that might affect
the worker, such as sitting time, desk height, uneven floors,
and the timing of breaks. If a job analysis cannot be done, a
detailed quantifiable job description reflecting the critical job
requirements, such as employers are required to have, is
essential. The results from the FPE can then be compared with
the job demands. Needless to say, the FPE tests should focus
on the specific tasks the worker might have difficulty with. In
a case of preemployment testing for a potential job, a more
comprehensive and generic assessment is needed to avoid a
potential mismatch between the worker and the job demands.
3. To determine sincerity of effort and consistency of effort during
assessment. Assessment results may be considered when a
determination regarding the level of disability is made related
to financial compensation. This has an administrative purpose,
especially in litigious situations where assessments of function
are used for medicolegal purposes. From a clinical viewpoint,
determining sincerity or consistency of effort and underlying
causes of submaximal performance may assist in guiding the
Chapter 9 Functional performance testing 398
Table 9.1 Definition of terms
Terms Definition
Evaluation The process of obtaining and interpreting data necessary for understanding the individual, system, or situation. This includes planning
for and documenting the evaluation process, results, and recommendations, including the need for intervention and/or potential
change in the intervention plan.
36
Assessment Specific tools, instruments, or interactions used during the evaluation process with comparison of the affected body part to the norm.
An assessment is a component part of the evaluation process.
36
Screening Obtaining and reviewing data relevant to a potential patient to determine the need for further evaluation and intervention.
Testing A standardized procedure of measurement.
Capacity The limits of the anatomic, physiologic, and psychologic systems of the person (depends on age, gender, genes, etc.). Physical
capacities refer to a level of functioning, often referred to as impairments in the terminology of the World Health Organizations
International Classification of Functioning (ICF). Impairments may include static and dynamic muscular strength, flexibility of the joints
and surrounding tissues, coordination, gait, balance, posture, and muscular and cardiovascular endurance.
Ability Capacity as modified by individual behavioral attitudes, in addition to external factors such as injury, pain, environmental and social
stressorsthe quality of being able to perform; a quality that permits or facilitates achievement or accomplishment.
Performance The act or process of functioning, sometimes measured by a performance scale or a performance test.
Performance areas Broad categories of human activity that are typically part of daily life, also called functional measures. They are activities of daily living,
work and productive activities, and play or leisure activities and include sitting, standing, walking, kneeling, squatting, lifting, pushing,
pulling, carrying, and manual dexterity.
focus of treatment. For example, an individual producing
submaximal effort may be anxious about reinjury or return to
work and may require intervention with a behavioral rather
than a physical emphasis.
4. To document outcome, achievement of goals, and or
effectiveness of the program. The viewpoint is primarily an
administrative one, with the emphasis on demonstration of
achievement of program goals.
5. To determine the level of disability. This may be used for the
settlement of a workers compensation claim or to determine
whether the disability is permanent or temporary. If disability
assessment is at issue, the FPE should correspond to the
information requested by the person determining the level of
disability.
44
6. To develop and improve treatment resources for service
provision and research.
What to measure
Most authors agree that the test components of the FPE include
the medical history, in which the individual factors associated with
MSDs
60
such as age, gender, physical activities/fitness, strength,
anthropometry (body mass index), and cigarette smoking, should
be noted; physical examination to quantify physical impairment
and to determine any contraindications for testing; work history;
pain assessment; and a variety of work-related performance tests
and self-reported functional limitations. There exists disagree-
ment as to how these components should be filled.
44
In the
following section the work-related performance tests and the
self-reported functional limitations are discussed.
Work-related performance tests
The contextual relationship of FPEs with work can easily be
understood from its original purpose. FPEs are predominantly
inspired by the taxonomy described in the U.S. Department of
Labors Dictionary of Occupational Titles (DOT). This taxon-
omy, although never formally tested for its validity, has gained
support in many countries around the world. The DOT classifi-
cation is similar to selected domains of the International
Classification of Functioning (ICF) and classifications such as a
back-specific classification called the functional assessment tax-
onomy.
33
Among others, the DOT provides information about
the work characteristics of most jobs in the United States in terms
of the physical demands these jobs place on the workers. The
demand classification is based on certain principles assumed or
demonstrated to be key elements in the nature of work.
These key elements are defined in the DOT as the physical
demands of a specific job and are called job factors. There are 20
job factors, with some of them broken into subfactors: standing,
sitting, walking, lifting, carrying, pushing, pulling, climbing,
balancing, stooping, kneeling, crouching, crawling, reaching,
handling, fingering, feeling, talking, hearing, and seeing. These job
factors then express both the requirements of the job and the
capacities a worker must have to meet or exceed those demands.
It has been stated that the content validity of FPEs based on the
DOT is sufficient and that most of the commercially available
FPEs cover many to all of these work characteristics.
40
Additionally, all jobs in the U.S. economy have been classified
into the following five levels of exertion: sedentary, light, medium,
heavy, and very heavy (Table 9.2). The physical demands strength
rating reflects the estimated overall strength requirement of the
job, expressed in terms of the letter corresponding to the partic-
ular strength rating. It represents the strength and endurance
requirements, which are considered to be important for average
successful work performance (see http://www.oalj.dol.gov/
public/dot/refrnc/dotappc.htm, accessed August 31, 2003).
In their systematic review of FCEs, King et al
44
found little
evidence in the literature of the inclusion of physical fitness
assessments in FPEs. This is in contrast to the finding that the
development of most FPEs is inspired by the DOT, in which
the energy requirements of jobs are defined. The level of aerobic
fitness directly affects the amount and intensity of physical
activity an individual is able to perform. Most physical activities
are described in terms of their energy or metabolic cost.
2,5
Physical activities are coded in metabolic equivalent (MET)
intensity levels. One MET is considered a resting metabolic rate
obtained during quiet sitting and equals an oxygen uptake of
3.5 ml/kg/min. The oxygen cost for physical activities ranges
from 0.9 MET for sleeping to 18 MET (running at 10.9 mph).
2
Aerobic fitness matters a great deal when performing physi-
cally demanding work. Workers with physically demanding
jobs include firefighters, the police and military, waste collectors,
and home care workers. For instance, firefighters need to be
highly aerobically fit to perform their job duties. Oxygen uptake
during fire suppression is about 25-35 ml/kg/min (7-10 METs),
which reflects how very physically demanding firefighting is.
Based on this observation 38-42 ml/kg/min has been most
frequently cited as the desirable VO
2max
level.
71
This is average
fitness for healthy males under 50 years of age, but an average
fit female of any age would not have this aerobic capacity. If
the aerobic demand of work cannot be met, premature fatigue
can put a person at risk for injury. For instance, it has been shown
that inactive firefighters have a 90% greater risk of myocardial
infarction than those who are aerobically fit,
58
and Linden
48
showed an inverse relationship between maximal oxygen uptake
and absenteeism in custom officers. Studies investigating workers
ought to describe the energy demand level of their job as set
forth by the U.S. Department of Labor (Table 9.2). Because of
the proven importance of aerobic fitness in the determination of
work capacity,
5
aerobic testing should be part of an FPE.
Self-reported functioning
Historically, an assessment of functional capacity was made by
asking patients about their activity levels. A large variety of ques-
tionnaires has been developed to measure patients perceptions
of their physical activity level and disability. Studies in patients
with chronic pain, however, have identified discrepancies
between self-report of physical activity and actual level of phys-
ical activity. In a number of these studies, the reported physical
activity level was clearly lower than the observed level. Objective
measurement of functioning as by FPE therefore seems war-
ranted. When comparing the results of FPEs with the results
of questionnaires, it has been shown that the outcomes are
substantially different and correlate moderately at best.
27,47,66
Chapter 9 Purposes 399
In one of these studies, 64 patients suffering from nonspecific
chronic low back pain (CLBP) rated themselves on three different
well-known low backspecific questionnaires as moderately to
severely disabled. The questionnaires were the Roland Morris
Disability Questionnaire,
67
the Oswestry Back Pain Disability
Scale,
18
and the Quebec Back Pain Disability Scale.
45
These same
patients, however, were able to perform activities at a physical
intensity level consistent with moderate to heavy work (classifi-
cation DOT). Correlations between the questionnaires and the
FPE results were poor to moderate.
66
Another striking example of the difference between self-reports
and actual activity levels was described by Verbunt et al.
78
The activ-
ity levels of patients suffering from CLBP and matched healthy
control subjects were measured continuously for 2 weeks using a
triaxial accelerometer. The results demonstrated that the mean
activity levels of the patients, who had rated their disability as
substantial, did not differ significantly from the control subjects.
It is clear that instruments based on self-report or based on per-
formance measure different dimensions of the same construct.
One of the reasons for this discrepancy might be that psy-
chosocial factors, such as depression and disability status, appear
to have a larger effect on self-report than on performance test-
ing.
83
Unfortunately, affective states appear to influence func-
tional performance as well. Poorer achievement on physical
performance testing of patients with CLBP has been linked to
fear of injury during movement, depression, pain expectations,
pain increase during testing, and the presence of a solicitous
spouse.
49,79,82,83
FPEs have been justly criticized for their lack
of measurement of psychosocial variables that might influence
testing and that may interfere with successful return to work.
In conclusion, a performance measure should be used to
measure a persons ability to perform an activity. Questionnaires
can be used to measure a persons self-reported ability to
perform an activity and to measure the psychosocial factors
that might influence both self-report and performance. It is
advocated to use both performance-based and self-report measures
to obtain a more comprehensive picture of a persons disability.
CHARACTERISTICS OF AN EFFECTIVE
FUNCTIONAL PERFORMANCE EVALUATION
When developing evaluations, both legal constraints and profes-
sional practice standards should be applied.
Legal constraints
Legal constraints challenge the validity of FPEs. Various pieces of
legislation, such as the Americans With Disabilities Act (1990),
the Age Discrimination Employment Act (1967), and the Federal
Uniform Guidelines of Employee Selection Procedure (1978),
require that function tests not discriminate against age and
sex and that appropriate accommodation in testing is created
for those who have impairments. Caution should be used when
comparing an individuals performance with normative data,
because the Americans With Disabilities Act prohibits this
method to make decisions regarding return to work, and deny-
ing a job to an individual with a disability based on data that
compares his or her functioning with that of the general pop-
ulation is illegal. The effects of age are confounded with work
capacity. Aerobic fitness declines with age.
3
Both muscle contrac-
tile and mitochondrial protein decrease with aging in sedentary
humans resulting in decreases in muscle strength and endurance.
With regard to lifting, Matheson et al
50
studied 531 healthy sub-
jects and found that age made a significant contribution to lift
capacity, which continued to be significant even when resting
heart rate and body mass were considered, suggesting that age-
linked decrements in aerobic capacity and musculoskeletal
strength may have a potentiating effect on decrements in lift
capacity. Age can therefore be a justifiable reason for early retire-
ment in persons with physically demanding jobs.
The most important legal constraint on functional testing,
aside from discrimination, is that it be evidence based (Daubert
v. Merrell Dow Pharmaceuticals, 1993). This case law requires
that peer-reviewed publications in scientific journals be given
precedence in determining acceptability of test-based evidence.
It also sets standards for legally acceptable scientific evidence.
Scientific peer review is essential for acceptability. Thus, when
big money is resting on an FCE, its credibility can be destroyed
by the opposing attorney when the test cannot meet those
standards.
55
Professional practice standards
The American Psychological Association and the American
Physical Therapy Association published professional practice
standards for measurement. In these models, there are five issues
that must be addressed in the selection and use of any functional
Table 9.2 Physical demands strength rating
Physical demand Occasional* 033% Frequent* 3466% of Constant* 67100% of
level of the work day the work day the work day Typical energy required
Sedentary 10 lbs. Negligible Negligible 1.52.1 METs
Light 20 lbs. 10 lbs. and/or walk/stand/ Negligible and/or push/pull of arm/leg 2.23.5 METs
push/pull of arm/leg controls controls while seated
Medium 21-50 lbs. 10-25 lbs. 10 lbs. 3.66.3 METs
Heavy 50-100 lbs. 25-50 lbs. 10-20 lbs. 6.47.5 METs
Very heavy Over 100 lbs. Over 50 lbs. Over 20 lbs. Over 7.5 METs
*Amount of force exerted to lift, carry, push, pull, or otherwise move objects, including the human body (1 lb = 0.45 kg).
METs, metabolic equivalents.
test in a patient population. These issues, presented in hierarchical
order, are as follows:
Safety: Given the known characteristics of the patient, the

procedure should not be expected to lead to injury.
Reliability: The test score should be dependable across evalu-

ators, patients, and the date or time of test administration.
Validity: The interpretation of the test score should be able to

predict or reflect the patients performance in a target work
setting.
Practicality: The cost of the test procedure should be reason-

able and customary. Cost is measured in terms of the direct
expense of the test procedure plus the amount of time required
of the patient, plus the delay in providing the information
derived from the procedure to the referral source.
Utility: The usefulness of the procedure is the degree to which

it meets the needs of the patient, referrer, and payer.
Safety
The safety of testing depends on a number of factors that
include the physical health of the patient, equipment safety, a
tried and tested protocol, and the experience of the evaluator.
No testing performed on the patient should lead to reinjury
or a new injury. Qualified professionals should administer the
FPE using a standardized protocol, both to ensure the patients
safety and to increase the reliability of the FPE. The medical
history and the physical examination to quantify physical
impairment together ought to determine any medical contraindi-
cations for testing. Medication use should be noted because a
variety of medications (such as alpha/beta-blockers, Ca
2+
channel
blockers) affects a normal exercise response and thus interferes
with physiologic measurement of the workload (i.e., by heart
frequency).
Safety criteria used during FPEs usually consist of the fol-
lowing. The evaluator must know of any medical constraints
before testing. The client should be instructed that he or she
may terminate testing at any point if deemed appropriate. A
heart rate monitor should be worn to prevent the heart rate
rising over a predetermined maximum. Most studies use a
maximum of 85% of the clients predicted average maximum
(220 age). Finally, the evaluator should terminate testing when
the client is at risk during the evaluation. This involves a pro-
fessional judgment based on medical information, the clients
history, the physical examination, and the performance during
the functional evaluation. No peer-reviewed data are available
on how often the evaluator would terminate testing for this
reason. The authors know of no reports in which new or rein-
juries during or resulting from FPEs are described. Among oth-
ers, evaluators may observe quality of movement, spinal
alignment, and body mechanics as a part of their safety deter-
minations. With regards to the latter, the use of a squatting
technique is usually advocated over a stooping technique. A
review of the biomechanical literature, however, has revealed no
significant differences in spinal compression between the two
techniques.
77
Maximal symptom-limited aerobic testing is safe, although
various facilities require supervision of a physician during test-
ing. The American Heart Association analyzed eight studies
related to sudden death during exercise testing.
21
The reported
rates were 0 to 5 per 100,000 exercise tests. A survey of the
Veterans Affairs Health Care System exercise laboratories found
an event rate of 1.2 per 10,000 tests of major cardiac events
(myocardial infarction, ventricular tachycardia) and no deaths
during 75,828 exercise tests performed within the last year.
56
In summary, it can be concluded that the risk of medical com-
plications is related to the underlying disease, and it appears that
the rate of death for patients, during exercise testing, is 2 to 5 per
100,000 clinical exercise tests. For details on cardiovascular test-
ing see http://ajrccm.atsjournals.org/cgi/content/full/167/2/211.
Reliability
Reliability involves the extent to which an evaluation is consistent
and free of error. This consistency may be over time (test-retest
reliability); between different raters, observers, or evaluators
(interrater reliability); between more than one identical session
rated by the same evaluator (intrarater reliability); or between
equivalent parts of the same test (internal consistency). Although
all types of reliability are important, establishment of test-retest
and interrater reliability are deemed most important in FPEs,
because it ensures that any change found in the assessment is
the result of change in the individual and not the result of meas-
urement inconsistencies over time or between examiners.
A number of factors may influence the reproducibility
of results. An important factor to consider is that of a poten-
tial learning effect and therefore the need for preliminary/
familiarization testing. Patients should practice the test at least
once to prevent undue anxiety and to increase mechanical
efficiency, especially when equipment is used with which the
patient is not familiar. An additional factor that may influence
the reproducibility of measurements is the time of testing.
Preferably, repeated testing should be undertaken at the same
time of day, as significant diurnal variation in results has been
reported.
25
Furthermore, the testing protocol, procedure, and
instructions to the patient must be rigidly controlled, because
these have been shown to significantly affect performance.
31,73
Finally, disease severity (pain severity) may also affect the vari-
ability of some measurements during exercise
42,82
and may affect
the interpretation of results in some patients with more severe
disease.
An area that may benefit from further development is that of
internal consistency. By examining the correlation between test
items, it may be possible to streamline evaluation batteries to
include only those items that assess necessary activities, rather
than duplicating items that assess the same or similar activities.
Reliability of evaluating work-related activities The most
recent review of the scientific evidence of the reliability of
FPEs was published in 1999.
39
It was clearly demonstrated that
the evidence for reliability of a wide range of FPEs ranged from
nonexistent to being investigated and reported in sufficient
detail. There did not appear to be a single FPE that had been
thoroughly and comprehensively investigated for all relevant
aspects of reliability. Since then, however, developers of FPEs
appear to have greater appreciation of the need to investigate
and report the reliability. To the authors knowledge, since
and including 1999, a number of papers have been published or
have been accepted for publication in peer-reviewed journals
(PubMed, key word: functional capacity evaluation reliability,
Chapter 9 Characteristics of an effective functional performance evaluation 401
1999-2003). Reports containing new data of different aspects
of reliability were identified about the following FPEs:
Baltimore Therapeutic Equipment Primus FPE: Test-retest

reliability of handgrip and lifting of 30 healthy subjects was
good, both for strength and for endurance protocols.
47
The
reliability of three other tests was also studied, with similar
results, but it may be questioned whether tests of isolated
wrist flexion and extension and elbow flexion should be
considered as functional.
Ergos Work Simulator: Test-retest reliability of seven upper

extremity items were tested on 12 healthy subjects, indicating
good reliability.
10
Similar to the Baltimore Therapeutic
Equipment Primus FPE, it may be questioned whether some
of the tests studied should be considered as functional
activities.
Functional Range of Motion Assembly Test: Test-retest relia-

bility of three items was tested on 51 healthy adults. Results
indicate moderate to good reliability.
52
Isernhagen Work Systems FPE: Five separate reports of

interrater and intrarater as well as test-retest reliability of the
material handling items indicate good overall reliability in
healthy subjects and patients.
24,30,41,61,63
Test-retest reliability
of two tests measuring maximum holding times of static postures
indicated good reliability in healthy young adults.
64
Test-retest
reliability of almost all items of the Isernhagen Work Systems
FPE, tested on 30 patients with CLBP, indicated a wide range
of reliability, varying from unacceptable to good.
12
Physical Work Performance Evaluation: Test-retest reliability

of nine main items of this FPE was tested on 24 subjects with
stable physical injuries (mainly back disorders). The results
indicate moderate to substantial reliability of the items tested.
76
Although many FPEs have still not demonstrated reliability
in peer-reviewed journals, the developments are positive. A
number of studies are performed with reasonable to good
scientific scrutiny, using both injured and uninjured samples, by
different researchers independent from each other. The studies
demonstrate that performance-based measurements, such as
FPEs, can be used to reliably evaluate a persons functional
capacity. They also demonstrate that although reliable at
the group level, the performances of injured individuals (with
CLBP) may vary substantially between occasions.
12
It appears
that this variance can in large part be attributed to the variance
in patient performances rather than measurement inconsisten-
cies over time or between raters.
30
Further research is needed,
however, to confirm this suggestion. Most of the recently
published studies have used the IWS FPE. This may be positive
for the body of knowledge of the Isernhagen Work Systems
FPE but not to the field of FPEs as a whole, because it is cur-
rently not known if, or to what extent, the knowledge gained
from one FPE can be generalized to other FPEs.
Reliability of evaluation aerobic capacity The intraindividual
day-to-day variation in measuring aerobic fitness (VO
2max
) is
between 4% and 6% in persons with no known cardiovascular
disease,
69
but the variation is larger in persons with known
chronic obstructive pulmonary disease (6-10%).
13
There is no
information on the reliability of maximal symptom limited
cardiopulmonary testing in persons with musculoskeletal pain.
Validity
Validity is usually considered to be the extent to which an instru-
ment measures what it is intended to measure. The validity of a
test refers to the appropriateness, meaningfulness, and usefulness
of the specific inferences made from the test results. Validity
depends on the purpose of the assessment and therefore the test
objectives. It is not a universal characteristic of an assessment.
No single measure is sufficient from which to determine an
assessments validity. These aspects imply that multiple studies
of the various forms of validity are required and that validity
must be evaluated within the context of the tests intended
purpose and a specific population. Several forms of validity are
relevant to FPEs: face, content, criterion-related (concurrent and
predictive), and construct validity (Table 9.3).
Sincerity of effort A confusing and inappropriate use of the
term validity occurs in some work-related assessments. The terms
validity profile, valid, conditionally valid, conditionally invalid, and
invalid effort are used by some FPEs. These terms do not refer
to the validity of the instrument or test battery results but
rather to the level of effort exerted by the client performing the
assessment. They are used to describe the level or sincerity of
effort exerted by a client and are not related to the measurement
concept of validity. The reader should be aware of this use of
the term and note that there is no scientific justification for the
use of the term validity profile as that term relates to functional
testing.
40
This subject of effort levels, sincerity of effort, and
pain behaviors is one of great importance for any form of
performance testing, including FPEs.
The term capacity connotes the maximum ability of the
evaluee, beyond the level of tolerance that is being measured.
50
Capacity is the evaluees potential, determined by physiologic
factors.
80
The use of the term capacity is somewhat misleading,
because capacity is rarely measured in a performance task, unless
the evaluee is highly motivated and trained to perform that
particular task. Examples of maximum task performance are
found when experienced athletes compete. When the evaluee is
an injured worker, the functional capacity is usually inferred
from evaluation of task performance. Even when the evaluation
task is designed to measure the evaluees maximum performance
level, this is achieved rarely.
The maximum level of performance that can be measured
is the portion of capacity the evaluee is willing to muster. Thus,
the performance of the individual depends both on his or her
abilities to perform and his or her motivation to perform. Two
items are of paramount importance in this: (1) how can capacity
and performance be differentiated when evaluating an individual
(are the results reflective of maximal or submaximal physical
abilities) and (2) what factors determine the motivation of
a patient to perform? Neither question can be answered with
scientific certainty at this time.
Methods that are being used to differentiate between a maxi-
mal and a submaximal performance (also referred to as sincerity
of effort) are Waddells nonorganic signs, descriptions of pain
behavior and symptom magnification, coefficients of variation,
correlations between musculoskeletal evaluation and function,
grip measurements, and the relations between heart rate and pain
intensity. Despite the widespread use of these methods, up to
1998 little had been published to address their reliability and
validity specific to the FPE setting.
46
Two studies published since
then have tested strategies to differentiate between maximal and
submaximal performance in a lifting test. Both studies report
promising results with regards to the sensitivity and the speci-
ficity of their methods to differentiate between maximal or
submaximal effort levels.
19,43
Both studies used healthy subjects,
which may not be representative for patients with musculoskele-
tal injuries. Additionally, both studies dichotomized between
maximal and submaximal, suggesting a greater difference than
presented in daily practice. There are large differences with the
group labeled as submaximal, because all subjects performing
between 10% and 90% of their maximum would fall into that
category. The challenge for future developments in this area is to
develop and test methods to differentiate between all levels of
effort (from light to maximum), not only on healthy subjects but
on relevant patient groups as well. Until then, clinicians should
remain careful in classifying their patients performance levels.
The second question deals with factors determining the
motivation of a patient to perform during an FPE. Watson
80
developed a model in which task performance during a per-
formance evaluation of patients with chronic pain is explained.
Other than physiologic factors, the following nonphysiologic
factors are postulated in the model: task familiarity and learning,
self-efficacy, pain self-efficacy, fear avoidance beliefs, current
pain level, and outcome expectancy. Based on these factors, a
patient may be motivated to perform to maximum capacity or
to terminate an activity before reaching maximum. It is impor-
tant to not only assess the extent to which a client is willing to
perform to his or her physical maximum, but also the reason(s)
why he or she performs as such. This assessment may require
knowledge beyond the professional capabilities of functional
capacity evaluators, often physical or occupational therapists.
Consistent with all major standards and guidelines of chronic
pain and work injury management, it is advocated to use the
services of a clinical psychologist or a behavioral therapist
to assess these aspects in conjunction with the evaluation of the
functional capacity. Their assessments, however, should meet the
same criteria of reliability and validity as any other assessment
and should not rely on self-reports or clinical expertise only.
Validity of evaluating work-related activities The last review
of the scientific evidence of the validity of FPEs was published
in 1999.
40
It was demonstrated that the evidence for validity
of a wide range of FPEs ranged from nonexistent to being
investigated and reported in sufficient detail. Very few FPEs were
able to demonstrate adequate validity in more than one area or
with more than one study. Since then, as was the case with the
reliability, developers of FPEs appear to have greater appre-
ciation of the need to investigate and report the validity. To our
knowledge, since and including 1999, several articles have been
published or have been accepted for publication in peer reviewed
journals (Pubmed, key word: functional capacity evaluation
validity, 1999-2003). Reports containing new data about differ-
ent aspects of the validity were identified for the following FPEs:
Baltimore Therapeutic Equipment Work Simulator: Real and

simulated lifting tasks were compared. The results suggest
the Baltimore Therapeutic Equipment Work Simulator
overestimates real lifting endurance performance in healthy
men. Lower physiologic stresses during the simulated task
suggest a significant difference between the real and simulated
loads.
75
DOT Residual Functional Capacity battery: Stooping, climb-

ing, balancing, crouching, feeling shapes, handling left and
right, lifting, and carrying appear to have construct validity
in chronic pain patients. In a sample of 155 chronic pain
patients, the DOT Residual Functional Capacity battery
Table 9.3 Definitions of validity
40
Face validity When a work-related assessment appears to measure what it intends to measure and it is considered a plausible method to do so.
Content validity The degree to which test items represent the performance domain the test is intended to measure. Content validity is usually
determined by a panel of experts who examine the relationship between test objectives and test items or by knowledge of the
normal practices used.
Criterion validity The systematic demonstration of the extent to which test performance is related to some other valued measure of performance
or external criterion. It is composed of concurrent and predictive validity and is considered to be the most practical approach to
validity testing and the most objective.
Concurrent validity Examines the correlation between two or more measures given to the same subjects at approximately the same time so that both
reflect the same incident of behavior.
Predictive validity Compares a subjects performance at the initial time of testing with performance obtained at a future date with another highly
valued measure or gold standard. For work-related FPEs a clients success when returning to work is a highly valued criterion.
Construct validity The extent to which a test can be shown to measure a hypothetical construct. For example, a work-related assessment may be
considered to have some support for construct validity if it is able to differentiate between clients who are able to lift safely and those
who do not, where the construct being measured is safe lifting ability (also called discriminant validity). Known Groups Method is the
most general type of evidence and involves the ability of the test results to discriminate between groups which are known to be
different (e.g., different diagnostic groups; different age groups; different occupational groups) in a theoretically appropriate manner.
Correlation with other tests involves the examination of the degree of convergence and/or divergence with other tests that are
presumed to measure the same or different constructs or traits.
FPEs, functional performance evaluations.
could not predict employment levels. However, if a patient
passes certain items of the FPE and has a pain level less than
5.4 (scale, 0-10), that patient has a 75% chance of being
employed at 30 months after treatment at the pain facility. It
was concluded that some DOT Residual Functional Capacity
battery job factors demonstrate a predictive validity in the
real work world.
20
A study on functional capacity and psy-
chologic measures concluded that psychologic variables were
related to measures of functional capacity measured at the
admission stage of a rehabilitation program and that psycho-
logic measures at admission were not good predictors of later
functional capacity measures. Additionally, functional capac-
ity measures were identified as important predictors of follow-
up employment outcome, but return to work could not be
predicted without taking pain into account.
16
Functional Assessment Screening Test: Some evidence was

described to confirm criterion validity because performance
of patients with CLBP was inversely related to self-reported
depression, disability, and different dimensions of pain
experience.
68
The strength of the relationships, however, was
not reported.
Gibson Approach to FPE: An expert review performed by

five occupational therapists supported the content validity
of aspects of this FPE.
26
Isernhagen Work Systems FCE: In a large cohort of patients

(n = 650; diagnoses not specified) studied retrospectively,
gender and time off work were found to be the strongest
predictors of whether or not the patients returned to work,
with performance on a lifting task adding little but signifi-
cantly to the prediction. Of those who did return to work, the
performances on two lifting tasks were related to the level of
work they returned to.
52
A study that examined the ability of
this FPE to predict a timely return to work in a workers com-
pensation environment by a worker suffering from low back
pain found that better performance on FPE was weakly asso-
ciated with faster recovery; however, the amount of variation
explained was small.
28,29
One task in the FPE was as predictive
as the entire protocol. Another study that examined the abil-
ity of this FPE to predict sustained recovery in a workers
compensation environment by a worker suffering from low
back pain found that better FPE performance as indicated by
a lower number of failed tasks was associated with higher risk
of recurrence. The validity of the FPEs purported ability to
identify claimants who are safe to return to work is sus-
pect.
28,29
Two separate studies confirm the concurrent and the
construct validity of this FPE, as it relates poorly to moder-
ately to different forms of self-reported disability.
28,29,66
A
moderate relation between FPE performance and pain inten-
sity was found,
28,29,65
and the relation between FPE perform-
ance and kinesophobia was found to be nonexistent.
65
Self-reports of function or prediction of function was poorly
related to actual function on tests measuring maximum hold-
ing times of maintaining postures.
62
Yet another study found
preliminary evidence in support of the ecologic validity of
this FPE; test results were not relevantly influenced by differ-
ences in test conditions.
64
Although many FPEs have still not demonstrated aspects of
their validity in peer-reviewed journals, the developments are
positive as well. A number of studies concerning different
aspects of validity are published. As was the case with reliability,
most of the recently published studies concern the Isernhagen
Work Systems FPE. Again, this may be positive for the body of
knowledge of the Isernhagen Work Systems FPE but not to the
field of FPEs as a whole, because it is currently not known if,
or to what extent, the knowledge gained from one FPE can be
generalized to other FPEs. One study in which upper lifting
performance was tested according to two FPE protocols
revealed significant differences in results.
37
This indicates that
differences in operational definitions of the activity tested, for
example lifting height and repetitions, really do matter. Even
though the amount of evidence is limited, it is suggested that
generalization between FPEs should not be made unless great
care is used.
In conclusion, the following can be derived from previous
40
and the above-mentioned publications. The construct validity
of FPEs based on the DOT classification is confirmed with
regards to the choice of activities that make up the evaluation.
It has been demonstrated clearly that the results of functional
capacity measurements differ substantially from results of self-
reports. Psychologic factors are known to influence test results,
but the extent to which they do, however, remains unclear and
warrants future research. The predictive power of FPEs with
regards to their ability to predict safe and lasting return to work
has not been clearly demonstrated and the results of different
studies appear to conflict.
It may be questioned whether FPEs will ever be found valid
for the prediction of a safe and lasting return to work. The
construct of workability is widely regarded as a multidimen-
sional construct. Whether a patient successfully returns to work
or not depends on more than functional capacity by itself. It is
paramount that an instrument measuring a single dimension
cannot be expected to assess a multidimensional construct. It
is therefore by definition incorrect to suggest or to claim that
the results of an FPE should be able to predict a persons work
ability or, even more complex, a successful return to work.
At best, one may expect from an FPE, in conjunction with
endurance testing, to measure an individuals functional ability
to perform work-related activities. This should be seen as one of
the prerequisites for a successful return to work. Seen in this light,
the role of the physical domain may prove to be a modest one.
Validity of testing aerobic capacity The gold standard for
determining absolute VO
2max
in an individual is by metabolic
measurement system analysis of O
2
and CO
2
gas in expired
air at regular intervals and attainment of a maximum heart rate
of at least 90% of age predicted maximum (220 age), a plateau-
ing of VO
2
and respiratory exchange ratio (RER) >1.0.
4,6,74
In nor-
mal subjects, the highest VO
2max
is obtained with treadmill
testing due to the quantity of the muscle mass involved, fol-
lowed by bicycle testing. VO
2max
achieved by bicycle testing is
reported to be 5-15% lower than with treadmill testing in normal
subjects.
34,35
Astrand and Rodahl
5
report a 5-7% difference in
maximal oxygen uptake between treadmill and bicycle testing in
well-trained subjects. Predicted VO
2max
ml/kg/min estimated
from arm exercise testing is 60-70% of leg exercise in normal
subjects. Normal females reach 65-75% of male VO
2max
.
6
The
lower oxygen uptake capacity in women may have to do with their
lower hemoglobin concentration and higher body fat content. In
both genders, oxygen uptake peaks at 18-20 years of age, followed
by a gradual decline with age. At the age of 65, the mean value
is about 70% of what it is for a 25-year-old individual.
Not much is known about the validity of exercise testing in
patients with chronic pain, because historically exercise testing
was mostly used in athletes, healthy subjects, or subjects with
cardiac and pulmonary problems. One study
81
compared tread-
mill, bicycle, and upper extremity ergometry (UBE) exercise test-
ing in a small (n = 30) sample of patients with CLBP. Indirect
calorimetry was used to determine oxygen uptake, and a three-
lead electrocardiogram was used to determine heart rates at
each minute of testing. Subjects were encouraged to do as much
as you can. The researchers used the modified Bruce treadmill
test, the Astrand-Rhyming bicycle test, and a UBE test. The test-
ing response for patients with CLBP was remarkably similar to
that of normal subjects. Significantly higher heart rates, peak
VO
2
, and predicted VO
2max
ml/kg/min were achieved by the
modified Bruce treadmill test than with the bicycle or UBE tests,
despite pain, consistent with normal subjects. Also, peak and
predicted VO
2max
showed gender differences consistent with
published results for normal subjects, supporting criterion
validity of aerobic testing in patients with CLBP by treadmill,
bicycle, or UBE. Further criterion validity for treadmill testing in
patients with CLBP was supported by the finding that prediction
equations for estimated maximum oxygen consumption
(VO
2max
) in patients with CLBP equal those in healthy sedentary
men and active women.
54
The treadmill is the most commonly used mode of testing
and is the apparatus of choice in the laboratory because exercise
intensity is easily determined and regulated. Most clinics have
access to a treadmill, making this a practical test. Determining
aerobic uptake by indirect calorimetric measurement is time
consuming and costly, however, and therefore not always of
practical use in the clinic. A variety of (submaximal) tests has
been developed estimating aerobic capacity when direct meas-
urement is not possible. These tests usually involve running/
walking for a given time or distance, such as the 12-minute
walk/run test, the shuttle test, and various step tests.
70
Longer
distances and shorter test times are associated with higher levels
of aerobic fitness. Other tests estimate VO
2max
by submaximal
testing and extrapolation to maximal heart rate by treadmill
walking or bicycling against a predetermined load with measure-
ment of heart rates.
3,7,14,23
These tests were mostly developed for
testing aerobic fitness in healthy people and were validated by
comparing actual measured VO
2max
with predicted VO
2
or to the
test performance. The validity of a number of these tests was
established for patients with cardiac or pulmonary problems,
17,32
but little has been done to validate these tests in patients with
chronic pain. In one study,
84
30 patients with CLBP underwent
bicycle ergometer testing using the Astrand-Rhyming method.
Predicted VO
2max
was calculated, both by using the nomogram
and by extrapolating VO
2
values obtained by indirect calorime-
try. The predicted VO
2max
values derived from the nomogram
were age corrected as suggested by Astrand and Rodahl.
5
There
were no significant differences between the nomogram and
calorimetric predicted VO
2max
values (p > 0.59) for the sample.
Individual predicted values by the nomogram method, however,
were shown to underestimate predicted VO
2max
by as much as
41% and overestimate predicted VO
2max
by as much as 38%.
On average, an error of 20% should be taken into account.
Similarly, estimating aerobic fitness in METs from a Bruce tread-
mill test, by comparing the level reached by the patient with
established MET norms for that level, results in significant
underestimation and overestimation of individual fitness levels
ranging from 25% to 33%.
84
It is important to understand that
the most accurate, and therefore valid, way to measure VO
2max
in
a single individual is through direct measurement of maximal
oxygen uptake. When determining fitness for duty it is extremely
important to get it right as a persons health and safety might
be at stake, not to mention his or her job security.
Aerobic fitness has construct validity in physically demanding
work. A vast body of knowledge has been accumulated on the
energy cost of physical work. In general, a person can carry on
all day without fatigue if the workload is less than 40% of the
individuals maximal aerobic fitness. Ergo, the less fit a worker is,
the less load this person can tolerate (or tolerate the same load
for a shorter amount of time). Pohjonen
59
investigated the effect
of aerobic capacity of home care workers on their ability to work
and found that poor average maximal oxygen consumption
(l.min
-1
; odds ratio, 3.1) indicated a high risk for reduction in
work ability, supporting the content validity of aerobic fitness.
A combination of back strength and aerobic fitness explained
31- 41% of the total variance of lifting ability in healthy
females.
53
No such data are yet available on persons with MSDs.
The predictive validity of aerobic fitness is mixed. As stated
before, inactive firefighters have a greater risk of myocardial
infarction than those who are aerobically fit.
58
Low cardiovascu-
lar fitness level was a risk factor for disabling back pain in a
prospective longitudinal study among aerospace manufacturing
workers.
8
In their landmark article, Cady et al
15
reported that
the frequency of injuries among firefighters was 10 times higher
for the least-fit group than for the most-fit group (n = 266 in
the least-fit group, n = 259 in the most-fit group). The cost
per claim for the 19 injured men from the least-fit group was
13% more than for the 36 injured men from the middle-fitness
group. Unfortunately, fitness levels were a composite of strength,
flexibility, and aerobic fitness, and it is unclear which compo-
nent of the fitness score was most important to the outcome.
Similar composite measures of fitness were identified as risk
factors for training injuries in the military.
9
Boyce et al,
11
how-
ever, reported that only 7% of absenteeism could be explained
by age, sex, and physical fitness among 514 police officers
35 years or older.
Practicality
Full-length FPEs usually require 4 to 6 hours of both the
patients and the evaluators time. Some FPEs divide this time
over consecutive days to evaluate the effects of the evaluation of
the first day, whereas other FPEs take up to a total of 22 hours
to perform, divided over multiple days. It has been suggested
that FPEs should shorten the time needed to collect data to
meet consumer demand.
44
This suggestion seems reasonable;
the length or comprehensiveness of the FPE should be tailored
to the purpose of the evaluation, and the results of recent stud-
ies suggest that is quite possible to do so. A shortened version
has been suggested as a screen to filter out those individuals who
self-limit their performances due to pain behaviors.
68
The need
for a 2-day evaluation for patients with CLBP could not be
confirmed.
61
Most recently, a strategy has been described to
develop a job-specific FPE derived from a full-length protocol,
reducing evaluation time from 6 to 1.5 hours.
22
Additionally,
research is warranted to streamline evaluation batteries to
include only those items that assess necessary activities rather
than duplicating items that assess the same or similar activities. It
has not been shown that longer FPEs are superior to short FPEs.
Utility
An FPE needs to have utility. There should be a justifiable
reason to perform an FPE; otherwise, such a test adds to the
health care burden unnecessarily. To be of value the test must
help the individual, physician, health care personnel, payer,
and employer to determine the individuals physical ability. It
should be able to identify an injured workers ability to return
to his or her usual work or be able to determine a persons
fitness for duty in case of a preemployment assessment. It can
also be used as a preprogram measure in functional restoration
or work-hardening programs to identify rehabilitation needs
and targets and to serve as an outcome measure postprogram.
Finally, an FPE should be able to identify persons with symptom
magnification or malingering.
CONCLUSION
The results of performance-based evaluations of work-related
activities are distinctly different from other types of evaluations.
They are, however, still not always incorporated into standard-
ized assessment batteries. The reasoning for this is unknown.
It is speculated that disadvantages believed to accompany FPEs,
one of which being the duration of the evaluation (several
hours), weigh heavily in the decision-making process. FPEs
may thus be impractical and expensive. Additionally, the psy-
chometric properties of FPEs have been critically reviewed in
the past. The results of these reviews have repeatedly shown that
FPEs lack foundation regarding reliability and validity. Recent
scientific developments of some FPEs have been presented
here. The results should force the general opinion into a more
optimistic direction.
The strength of assessing the functional domain by means of
a reliable and valid FPE may be to confirm or refute a patients
belief that his or her capacities are insufficient to perform
work. From a cognitive-behavioral perspective, such a belief to
be proven false through an FPE is beneficial, because it confronts
the patient with maladaptive behaviors and belief systems. The
effect of such a confrontation may allow for introduction of
different, more effective, and efficient interventions directed
toward a safe and lasting return to work.
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C HA P T E R
The Physicians Role in Disability
Evaluation
Robert H. Haralson III
Throughout history most social systems have been forced to deal
with the problems of a population containing individuals who
have been injured, who are suffering from chronic disease, or
who simply through aging have a reduced ability to perform the
daily activities required for survival both at work and at home. In
nonindustrialized societies, the physical disabilities associated
with aging are often perceived as being accompanied by increased
wisdom and experience. Older members of these societies thus
become the teachers and decision makers for the communities.
Those individuals with minor restrictions in ability are given tasks
around the home in the preparation of tools or food and the care
of children. Because of a lack of medical and health resources, the
severely disabled inevitably succumb to infection or malnutrition
and, occasionally in certain societies, some form of ritual suicide.
In modern industrialized nations, on the other hand, those
individuals who are disabled have access to a wide variety of
health care facilities and social resources that attempt to reinte-
grate them into the community. To avoid abuse of these benefits,
mechanisms have been developed to assess degrees of disability
and assign responsibility for its cause. Rapid growth in the cost of
these benefits has led to an increasing emphasis on the effects of
chronic illness and injury on life-style and work capacity.
Extensive legislation has established rules for the provision of
benefits to those unfortunate enough to have reduced capacity as
a result of chronic illness or injury. Such legislation includes
workers compensation,
30
Social Security,
35
and the Americans
with Disabilities Act. Furthermore, multiple private and industrial
programs and insurance policies have been established to assist
individuals who are ill, injured, or otherwise disabled.
In almost every determination of disability or ability, legisla-
tion or private contract requires the input of at least one and often
several licensed health care practitioners. The basic assumption is
that the individual who is most competent and best trained to
determine the ability of other members of society to perform
specific duties is the medical physician. This decision has been
based not on any well thought out or scientifically investigated
competence but instead has fallen on the physician by default.
Unfortunately, the skills necessary to perform this social function
are not as a rule taught in medical school and until recently have
not even been the subject of significant research. To some extent,
therefore, physicians asked to perform this task must do so based
on personal opinion, great variability in experience, and usually
poorly thought out legislation or social contracts.
ETHICS ASSOCIATED WITH DISABILITY
EVALUATION
Physicians required to determine a degree of impairment and the
ability or inability of an individual to perform specific tasks must
deal with a number of ethical dilemmas not commonly consid-
ered in clinical practice. In comparison with disability evalua-
tion, basic clinical practice is relatively simple. Most physicians
perceive their ethical duties as to care for and to relieve patient
symptoms or illnesses by whatever means they can, without any
consideration of the social position of their patients or the pres-
sures exerted from outside authorities. The welfare of the patient
is inherent in the Hippocratic Oath. The contract for services is
between the doctor and the patient.
When a physician is required to change roles and issue opin-
ions on legal matters, one of two things happens. If their opinions
will impact their own patients ability to obtain compensation or
to work in particular occupations, physicians naturally are biased
in favor of each patients position in the matter. Failure to take a
patients position could seriously jeopardize the patient-doctor
relationship and adversely impact the ability to manage the
patients health care needs. On the other hand, an inability to jus-
tify a particular position that the patient may hold strongly can
seriously jeopardize the physicians credibility within a workers
compensation or other health care delivery system. Studies by
Brand and Lehmann
8
demonstrate that many treating orthope-
dists are willing to exaggerate a situation to benefit the patients
position in third-party actions.
If physicians are functioning as independent medical examiners,
their ethics are subject to pressure from the referring source.
Inevitably an independent medical examiner receives a referral
because of disagreement between the insurance carrier or agency
and the patient or treating physician. Regardless of the honesty
10
of the independent medical examiner, insurance carriers tend to
refer insured persons to physicians with track records who are
likely to support their positions. Further difficulty arises in that
patients tend to distrust independent medical examiners and
may attempt to justify their perceived positions through embel-
lishment and other forms of exaggerated behavior. Although the
criteria of Waddell and associates
37
can be used to identify cer-
tain of these factors, the assessing physician may lose sympathy
for such an individual regardless of an underlying disability that
may be camouflaged by this behavior. Physicians must be care-
ful to remember that some patients who exaggerate can also have
real pathology. In our system, patients are paid to be sick, and
the sicker they are, the more they are paid. Patients who learn to
act sick cannot get well.
18
In that situation, it is a natural human
response to advocate for ones position.
Hadler
17,19
seriously questioned the ethics of any physician who
performs disability evaluations, arguing that the notion of impair-
ment rating is fatally flawed and should be discarded completely.
He believes that diminished work capacity as a result of muscu-
loskeletal disorders, the most common cause of disputed disability,
is overwhelmed by psychologic and sociopolitical confounders and
cannot be determined in the medical setting. The marked variation
in medical opinion as to the nature and extent of disability given
similar clinical findings tends to support this view. Further support
comes from the work of Waddell et al,
36
Bigos et al,
5,6
and Deyo
and Diehl,
14
which demonstrates that the greatest predictors of dis-
ability from low back pain are psychosocial rather than pathophys-
iologic. Other studies demonstrated that by far most factors
predicting return to work are psychosocial rather than physical.
Treating physicians, most of whom have not had specific
training in impairment evaluations, are least prepared to render
objective ones. Data show that surgeons who perform large
numbers of cardiovascular operations and total joint replace-
ments achieve better outcomes; data suggest also that physicians
who perform large numbers of independent medical evaluations
are more accurate and consistent. Training and practice improve
outcomes in impairment evaluations just as they do in surgical
procedures. Just as patient treatment relies on scientific rather
than anecdotal data, so-called evidenced-based medicine applied
to impairment or return-to-work determinations results in opin-
ions that are fairer to the employee, employer, and insurer.
MEDICAL OPINIONS REQUIRED DURING
DISABILITY EVALUATION
The physician faced with a demand for a disability evaluation
must reach a number of conclusions and provide opinions on
the topics explained on the next few pages. Not all disability
schemes require that the physician address each issue.
Furthermore, specific requirements or definitions inherent in the
administrative procedure of a specific disability system might
not be included in this outline.
Date of permanent and stationary status
Either a treating or an assessing physician must determine the point
of maximum medical improvement or permanent and stationary
status, the point at which administrative rules concerning disabil-
ity begin to take effect. It is virtually impossible for an accurate
permanent disability evaluation to be made before declaration of
the point of maximum medical benefit. Within some jurisdic-
tions with a time limit, however, it is occasionally necessary to
render an opinion before maximum medical improvement is
reached. In those situations, commonly involving an arthritic
joint that will ultimately lead to total replacement, the physician
should state the disability at that time but indicate that improve-
ment or worsening is possible. In some cases the physician may
include an estimate of future impairment.
Although there is no universal rule, it is reasonable to assume
that the time of maximum medical benefit or permanent and sta-
tionary status is the point at which the patient has shown no sig-
nificant change for a number of weeks and it is unlikely that future
medical treatment will improve the medical status or level of dis-
ability. The American Medical Association (AMA) guides
2
define
maximum medical improvement as the time from which the patient
is unlikely to experience significant improvement within 1 year.
Residual subjective complaints
Once it is determined that the patient has reached permanent
and stationary status, most agencies request a statement regard-
ing the ongoing symptoms. The discussion of subjective com-
plaints includes a list of the specific body parts or functions that
are affected and the manner in which they compromise the
patients functional ability in both work and recreation. This can
often be obtained by simply asking the patient to list all symp-
toms and discuss how they affect all activities. It is useful to note
how patients perceive not only their disabilities but also what
they consider to be their abilities for specific functions.
Residual objective findings
Inevitably, the physician is asked to list the abnormalities found
on physical examination as well as any and all abnormal labora-
tory and imaging findings. In certain disability evaluation sys-
tems such as Social Security, a simple listing of the objective
findings is all that is necessary.
10
Other systems, such as the AMA
guides,
2
require not only lists of objective findings but also sever-
ity classifications of loss of range of motion (ROM), sensation,
strength, or coordination.
Another decision often required in this setting is a statement
as to whether the subjective complaints are consistent with and
confirmed by the objective findings. Signs of nonorganic clini-
cal patterns, such as those developed by Waddell et al
37
for low
back pain, may be requested by name or by insinuation.
Diagnosis
Although many disability evaluation systems require a diagnosis,
it shows little correlation with the amount of impairment and,
for that matter, disability. Many workers function quite well
with significant impairments, including amputations of upper
and lower extremities, whereas others are totally disabled by less
Chapter 10 The physicians role in disability evaluation 410
significant impairments. Disability is more closely tied to psy-
chosocial issues than to diagnosis. With regard to the spine,
physicians should remember that in the absence of obvious
radiculopathy, examination of a patient with acute neck or back
pain rarely identifies the pain generator or yields a specific diag-
nosis. A diagnosis of back sprain implies tearing of ligaments, a
condition that probably rarely exists. Examiners are encouraged
to use more generic terms such as back pain or lumbago.
Making a specific diagnosis in an extremity is usually much
easier than in the spine, but even here pain only syndromes
can be a problem. The examiner should follow the International
Classification of Diseases coding rules and diagnose only to the
point at which the specificity is certain.
24
Return-to-work determinations
Determining when a patient should return to work is now one of
the most controversial requirements of treating and evaluating
physicians. It has been commonplace for physicians to take
workers off work for extended periods of time for conditions that
should not prevent some kind of work activity. Mounting evi-
dence shows that the longer a patient is off work for whatever
reason, the less likely that he or she will ever return. Several stud-
ies demonstrated significant increases in morbidity and mortal-
ity in people who are no longer working.
16
Very few conditions
would in and of themselves prevent a worker from being at work.
One is coma; another is lower extremity injures in which the use
of ambulatory aids is precluded by concomitant upper extremity
injuries. It has been stated that if an employee can commute and
be at work, there is no reason for absence.
34
Data indicate that in
the long run it is less expensive for the employer to have an
employee at work doing nothing than for the employee to stay
at home where deconditioning continues; if the employee can
actually do meaningful work or even attend rehabilitation, the
rewards are even greater. With proper accommodations, early
return to work should be the norm, but many companies still do
not have programs to allow it. This is especially true of the most
common condition to cause loss of work, acute back pain.
15
Return-to-work decisions are based on three concepts: capac-
ity, risk, and tolerance. Capacity is what a patient can do at a par-
ticular time. Very few people function at full capacity, which can
be increased by conditioning and training. It is therefore current
ability that is being assessed, a difficult task because it requires
the cooperation of the patient. The standard method is func-
tional capacity evaluation, implying that one can assess the job
requirements, perform a functional capacity evaluation, and
match the two. It has not been shown, however, that functional
capacity evaluations are valid for assessing abilities with regard to
low back pain, for example. Functional capacity evaluations are
more useful in limited situations: jobs involving only simple
motions by the extremities where testing simulates the require-
ments and infrequent near maximal lifting where isometric
strength approximates. Although many rating physicians still use
functional capacity evaluations in any situation because they are
helpful to corroborate clinical impressions, results must be inter-
preted in the context of their lack of proven scientific validity.
Risk of reinjury or worsening of a condition greatly concerns
physicians and employers. Physicians are reluctant to send
employees back to work early for fear that the requirements
might cause the condition to recur or delay the recovery;
employers fear that it will lead to another claim. Data show that
the chances of significant recurrent injury after an episode of
acute low back pain are in the range of 1.7 times the incidence
in workers with no previous back pain. The incidence of back
injury claims in the normal population is 3 per 100 workers, so
that of recurrent claims in workers with previous back injuries is
5.1 per 100, an increase of 2 per 100. The cost of these additional
claims is miniscule compared with that of leaving all 100 workers
off work for extended periods of time.
36
Data on return to work
after myocardial infarction are similar.
22
The main determinant of an employees decision to return to
work is tolerance of mild discomfort and inconvenience. Are the
rewards greater for returning to work than for being absent?
Some employees fear returning to work; many know of an
acquaintance who is chronically disabled by back pain. Many
employees need convincing that by benefiting their health and
well-being, return to work is in their best interest, as proven by
numerous studies.
23
Although the pursuit of pain relief decreases
function and increases pain, the pursuit of increased function
decreases pain.
One difficulty in this setting is to differentiate the capabilities
of a normal healthy person of similar age, sex, education, and
body build. These can often be inferred by National Institute for
Occupational Safety and Health or other standards.
31
It then
becomes necessary to determine how a particular individual
being evaluated differs from normal and how this variance
affects the ability to do specific work. Nowhere in medical or
even in specialty training does this determination approach a sci-
ence, but two references give some reasonable guidelines for
return to work: the Official Disability Guidelines
13
is categorized by
diagnosis and The Medical Disability Advisor
32
is categorized by
diagnosis and procedure. A study by Buchbinder et al
9
showed
that merely educating patients about how returning to work was
in their best interest significantly reduced their time off.
Work and activity ability
In addition to determining if and when an employee may return
to work, physicians are often asked to prescribe activity limita-
tions. The Occupational Safety and Health Administration guide-
lines are very restrictive and do not reflect the science. Bigos,
4
the
lead author of the AHCPR (Agency for Health Care Policy and
Research) clinical practice guidelines for low back problems in
adults, indicated that government personnel changed the physicians
recommendations regarding weight restrictions. Mounting evidence
indicates that the restrictions physicians habitually place on workers
are overstated.
11
With respect to acute low back pain, Malmivaara
et al
27
wrote the Activity Paradigm, the principle of which is to
return to activity as normal as possible as soon as possible. Although
some other conditions obviously require temporary limitations of
activities, workers should be reintroduced to the work force as early
as possible and to normal activity if at all possible. This is benefi-
cial for their physical rehabilitation as well as for their psyches.
There is little evidence, for instance, that patients need restric-
tions after recovering from episodes of acute back pain. Although
the most common restriction is lifting, little evidence has shown
Chapter 10 Medical opinions required during disability evaluation 411
that lifting in and of itself causes back pain. Most back injuries,
in fact, are associated with light loads. Studies do not show that
lifting follows the dose-response curve in which the more one
lifts, the more it hurts. When proper lifting techniques are used
and the load lifted does not correlate with injury, twisting during
lifting is more likely to aggravate back pain.
Causation
Although causation is more a legal doctrine than a medical one,
examining physicians are often asked to render their opinions. In
medical school we are taught to take a history from the patient and
to rely on it when forming opinions. When a patient indicates that
a pain started at a certain time and in association with a certain
activity, it is not the examiners duty to investigate whether he or
she is telling the truth. Physicians are asked to judge if the injury
described by the patient could have reasonably caused the condi-
tion. In many extremity injuries, objective findings on physical
examination and imaging studies make the etiology obvious, but
if the claimant complains of back pain or one of the other pain-
only conditions like carpal tunnel syndrome or lateral epicondyli-
tis, deciding causation is more difficult. Back pain is ubiquitous:
About 80% of humans experience it at some time during their
lives. Degenerative disk disease is present in essentially every
human after age 50. Thirty percent of magnetic resonance images
in patients with no back pain are read as positive for ruptured
disk.
7
Identical twin studies have shown no difference in the
amount of degenerative disk disease in hard-working and seden-
tary twins, suggesting that it is mostly hereditary.
3
It is therefore
difficult to attribute much of the back pain we see to industrial
injuries, but in todays legal climate if a worker states his or her
back pain started on the job, it is assumed to be compensable
unless proved otherwise. Although we do have scientific infor-
mation on injury response, it is difficult to attribute back pain to
a particular injury when the onset of pain was more than 24 to
48 hours afterward. In addition, there is mounting scientific evi-
dence that carpal tunnel syndrome is rarely entirely secondary to
work tasks.
12
Apportionment
Physicians are often asked to render an opinion as to how much
impairment is due to a particular injury and how much was pre-
existing, because the legal and insurance industries assume they
are trained to do so. Unless an impairment evaluation has
occurred before the injury in question, however, this is a very dif-
ficult task. In fact, it is mostly guesswork on the part of the exam-
ining physician, one that may not be appropriate. Sometimes the
physician should decline to offer an opinion and state that it is
medically impossible to apportion. This is true especially in a
claimant with a work-related back injury, preexisting degenera-
tive disk disease, and previous episodes of back pain not associ-
ated with work or in one who has had multiple work-related back
injuries. In the absence of any objective changes in anatomic
structures that are caused by the injury in question, the only dif-
ference is the amount of pain the claimant is experiencing, which
cannot be quantified or qualified. In the absence of a formal
impairment rating before the injury in question, accurate appor-
tionment is very difficult, if not impossible.
If the physician can reconstruct an impairment scenario that
existed before the present condition, however, apportionment
may be possible. If a worker previously had a lumbar radiculopa-
thy treated with surgery that relieved pain, for instance, then he
or she would be rated as a lumbar category III and at a 10%
impairment. If radiculopathy recurred in the same spinal area,
whether or not the condition required surgery, the worker would
now be rated by the ROM method. Subtracting the 10% cate-
gory III rating from the ROM rating would allow the rater to
apportion the remainder to the new injury.
2
Though the two
methods of rating are not totally compatible, this is one way of
estimating apportionment.
Ongoing and future medical
care requirements
At times physicians are asked to estimate future medical costs, a
very difficult task because costs include not only physician fees
but also hospital charges, which can be variable and are usually
significantly higher. In addition, predictions about future med-
ical care are inexact because of the variation in the type of treat-
ments suggested by different physicians. The care of back pain is
a prime example. The incidence of back surgery in different parts
of the country varies significantly, and the inference is that some
physicians are more likely than others to opt for surgical treat-
ment. Like return to work after a back injury, future medical care
of back pain, moreover, is steeped with psychosocial issues.
Predicting the rate at which damaged joints will lead to total
replacement is inexact also, because psychosocial issues may
influence the treatment chosen. Despite the difficulties, physi-
cians must make estimates in some cases and should reflect the
inaccuracy of such endeavors in their reports.
PRINCIPLES OF IMPAIRMENT
DETERMINATION
The workers compensation system is administered by each state,
each of which requires use of its own method of evaluating per-
manent impairment. The standard text for determining perma-
nent impairment is the AMA Guides to the Evaluation of Permanent
Impairment,
2
which is required or recommended by some 40 states.
Some states name a specified edition, whereas others require the
use of the most current version: Texas, for instance, recently
switched from the third to the fourth edition, and in 2004
California began using the fifth edition. Some states have a
hybrid system; for instance, West Virginia uses the fifth edition
but will not allow use of the ROM system to evaluate spinal dis-
orders. A few states have developed their own unique systems,
and at least one state allows the physician to use any method he
or she wishes.
The AMA guides are just that, not an authority engraved in
stone. Some conditions such as shoulder disorders are not cov-
ered well. A patient with a rotator cuff tear that was successfully
repaired with a full ROM probably has some residual impair-
ment but would be classified as not impaired according to the
ROM method. It is therefore permissible to depart from the
AMA guides if the reasons are set out in the report. Another
example is cervical category IV, where a patient with an arthrode-
sis of one level for radiculopathy is assigned at least 25% impair-
ment when in fact this standard treatment for disk pathology in
the cervical spine seldom results in much disability.
The question of who should perform the evaluation is contro-
versial. Some believe that it should be the treating physician who
should know the most about the examinee. Data suggest, how-
ever, that an independent physician who has never treated the
patient is more objective.
20
Physicians are taught in medical
school to advocate for their patients, a precondition for good
doctor-patient relationships. This requirement places the treating
physician in a difficult position, especially if the outcome of
treatment has been less than satisfactory.
Although activity is very complicated and often not intuitive,
few physicians have had any formal training in impairment eval-
uation. Such an evaluation does, however, require the skill of a
physician who is performing a complete and accurate history
and physical examination and interpreting objective and subjec-
tive findings. Physicians must learn to objectify subjective find-
ings.
21
Patients in the workers compensation setting tend to
exaggerate their symptoms, a natural human response to a system
in which the payment level corresponds to that of an illness. The
examining physician must be adept at sorting out contradictory
findings so that the impairment evaluation is fair to all parties.
Over-interpretation of subjective findings may lead to an inordi-
nately high rating, but care must be taken not to underrate only
because a few nonphysiologic signs are present. Some claimants
who have learned to exaggerate as part of illness behavior may
have real pathology.
It is incumbent on all evaluating physicians to become adept
in impairment evaluations; several training alternatives are avail-
able. The American Academy of Disability Evaluating Physicians
1
holds several courses on impairment evaluations per year through-
out the country, as does the American Board of Independent
Medical Examiners; both organizations offer a certifying exami-
nation. Several specialty societies have begun to include impair-
ment evaluation on their curricula, and a number of states
require continuing medical education in evaluations to be able
to perform them. These states either provide the continuing
medical education themselves or arrange with one of several
organizations to teach the subject.
USING THE AMA GUIDES FOR RATING
IMPAIRMENT
Because the use of the AMA guides is required or suggested in
most states and may serve as a template in jurisdictions that do not
require its use, and because the musculoskeletal system is the most
commonly used section, it is appropriate in this text to have a brief
discussion of some of its principles. Physicians must understand
the difference between impairment and disability. Impairment is
defined as loss of function of a body part. Disability includes
impairment, motivation, education, socioeconomic status, and
several other parameters that are difficult to measure. The AMA
guides rate impairment, not disability. Although some jurisdic-
tions use a mathematical formula that includes the impairment
rating to determine disability and monetary award, the AMA
guides suggest that this is inappropriate.
The AMA guides attempt to provide a method of rating
impairments that allows multiple physicians to arrive at similar
ratings. Response to treatment and several of the Waddell signs
are examples. Physicians performing impairment ratings using
the AMA guides must thoroughly understand the entire text,
especially Chapters 1 and 2. It is insufficient merely to turn to a
picture of an anatomic part and read an impairment rating from
the adjacent chart or table. There may be several appropriate
ways to rate a patient, and the rater must decide which one is
most accurate for the particular case.
Differences between the fourth
and fifth editions
There are several differences between the fourth and fifth
editions of the AMA guides. The biggest difference in the spine
section is that in the fourth edition, the impairment was calcu-
lated for the injury, not for the result of treatment. This meant
that findings that occurred any time during the patients course
were enough to place a patient in a category and the results of
treatment made no difference. In the fifth edition, treatment is
considered, and to be significant, findings must be present at the
time of the examination. In addition, in the fourth edition there
was no way in the diagnosis-related estimate (DRE) method to
consider arthrodesis, but in the fifth edition it is included in the
definition of loss of structural integrity. Finally, the ratings in the
DRE method include a 3% range: The physician is allowed to
increase the rating up to 3% if there are ongoing objective signs
of continuing problems. The rating should not be increased only
because of a pain complaint. The differences between the fourth
and fifth editions with respect to the upper and lower extremities
are minimal. A very helpful addition to the lower extremity
section is the matrix on page 526 that assists in the decision as to
when to combine the different methods of evaluating the lower
extremity.
Pain
Chapter 1 of the AMA guides states that physicians recognize the
local and distant pain that normally accompanies many disorders.
Impairment ratings in the AMA guides already have accounted for
commonly associated pain, including that which may be experi-
enced in areas distant to the specific site of pathology.
2
Because a
3% range is already included in the spine DRE ratings, Robinson
et al
33
argued that it is never appropriate to double dip and add
ratings for pain to ratings in the spine chapter. On the other hand,
if an examinee has pain defined as ratable according to the AMA
guides, then one can use the pain chapter (Chapter 18) to award
up to an additional 3% impairment.
Spine impairments
In both editions, the DRE is the method required to rate all
patients who have sustained an injury to the spine, except for a
Chapter 10 Using the AMA guides for rating impairment 413
few conditions in the fifth edition for which the ROM method is
used. In most cases, disk pathology is assumed to be secondary to
an injury. For cases of recurrent radiculopathy in the same spinal
area, fractures at multiple levels in the area, or multilevel loss of
structural integrity (multilevel spinal arthrodesis), the ROM
method is used. This practice has led to inordinately high ratings
for patients who have undergone one-level diskectomy and
fusion for disk pathology in the cervical spine. Recurrent injuries
not involving radiculopathy should not be rated by the ROM
method. If it is followed, the AMA guides require the use of an
inclinometer rather than a goniometer for measuring the motion.
The rating physician should be aware that the ROM method
requires the inclusion of all three of its components: ROM
(Table 15-7) and any neurologic component from Tables 15-17
or 15-18 if appropriate. These ratings are combined using the
Combined Values Tables at the back of the book. Controversy
exists about the accuracy of spinal ROM measurements and
the relationship of loss of ROM to impairment and/or disabil-
ity, but at this time the ROM method is still used in certain
default conditions.
25,26,28-29
Spinal injuries that involve injuries to the spinal cord or
cauda equina are rated using Table 15-6, which combines seven
tables from the neurologic chapter. Values from each table are
combined with each other and then that value is combined with
a rating from DRE categories II through V. The rating from the
DRE method awards impairment for the local condition (frac-
ture or radiculopathy), whereas Table 15-6 does so for the cord
damage.
Upper extremity impairments
The function of most of the upper extremity is to move the hand
in a position to perform a task. As a result, ROM measurements
are of paramount importance; a reasonable way to assess impair-
ment; and the mainstay of rating the shoulder, elbow, and wrist.
The hand itself is rated by combining values for amputation, sen-
sory deficits (based on the two-point discrimination method),
and loss of motion. Because there is usually no motor loss in
hand injuries below the wrist, strength measurements are seldom
necessary.
Nerve injuries are rated by estimating the magnitude of sen-
sory and motor deficits using the appropriate tables and then
multiplying that figure by the maximum loss for each named
nerve, branch of the cervical plexus, or nerve root. Vascular
deficits are rated using a specific table. A number of other con-
ditions such as synovial hypertrophy, joint malalignment, and
joint instability are rated by estimating the magnitude of the par-
ticular problem using Tables 16-9 through 16-24 and multiplying
by the maximum value for each particular joint from Table 16-18.
Recurrent dislocation of the shoulder has its own table in which
rating is based on frequency.
If there is no other method to assess impairment of the upper
extremity accurately, one may use loss of strength. Tables in the
AMA guides estimate normal grip strength by occupation and
age as well as by normal pinch strength. By subtracting the
patients strength from the normal strength and dividing by
the normal strength, one calculates the loss of strength index.
Table 16-34 then estimates impairment. This method should not
be combined with other methods of assessing impairment in the
upper extremity.
Normally only one method is used, but if more than one accu-
rate method is available to assess impairment, it may be appropri-
ate to use them all and award the highest value. Occasionally,
methods are appropriately combined when the impairment is not
adequately estimated by one. An example would be a distal elbow
fracture that injured the ulnar nerve. The elbow injury would
appropriately be rated by ROM measurements, but these would
not include residual impairment from the ulnar nerve injury,
which would require the use of the peripheral nerve ratings. Total
upper extremity rating would then be calculated by combining
the two. Values for fingers should be converted to the hand, the
hand to the upper extremity, and the upper extremity to the body
as a whole using Tables 16-1 to 16-3.
Carpal tunnel syndrome rating uses the neurologic method.
Sensory and motor deficits are determined and graded using
Tables 16-10 and 16-11, although the two-point discrimination
method or the Semms-Weinstein monofilaments may help the
evaluator grade the sensory component. Grading motor loss usu-
ally does not require formal strength testing but may be helpful
in verifying the validity of the examination.
Evaluating physicians are strongly encouraged to use the
charts on pages 436 and 437. These charts guide the user through
the complicated upper extremity process and give specific
instructions about adding versus combining values.
Lower extremity impairments
Unlike the upper extremity, the function of the lower extremity
is to provide a stable platform for standing or ambulation.
Though important, ROM is therefore less so than in the upper
extremity, so several other assessment methods are available.
Table 17-2 is a guide to when these methods should or should not
be combined. Strength loss, muscle atrophy, and gait derange-
ment are usually used when there is no other good way to rate
the patient. Limb length discrepancy, on the other hand, may be
combined with several other methods. In some situations, loss of
ROM is the best way to assess impairment even in the lower
extremity. Impairments for loss of motion in each direction are
added in each joint. For instance, impairment in the hip would
be calculated by adding impairments for all six motions.
The impairment for complete ankylosis of a joint is calculated
by assessing impairment for ankylosis in optimum position and
then adding impairments for malposition, if present. In the hip,
for instance, this would mean a possible addition of five more
estimates (there are no tables for ankylosis in extension). The sum
total of all impairments in a badly deformed hip may be more
than 100%, in which case the whole person impairment is the
40% assigned to the lower extremity because the extremity impair-
ment cannot be more than 100% of a part. A rating method
unique to the lower extremity is that for narrowing of a joint sec-
ondary to arthritis: To calculate impairment, narrowing on x-ray
examination is compared with standard measurements for nor-
mal joint space.
The AMA guides contains a large section of diagnosis-based
estimates, including total joints, malaligned fractures, and liga-
mentous instabilities. Total joints are rated based on a point
system that reflects the function of each. Total ankles have not
been addressed. Meniscal pathology is rated depending on the
treatment. Partial excision is rated less than total. Because it was
not common at the time the fifth edition was published, meniscal
transplant is not mentioned but is now receiving more attention.
Most patients have some narrowing of the joint, and in these
situations combining values for the narrowing and for partial
meniscectomy seems appropriate.
Peripheral nerve injuries are rated similarly to those in the
upper extremity, with Tables 16-10 and 16-11 being used to grade
the deficits. Skin loss in the lower extremity can cause significant
impairment in certain locations such as the ischial tuberosity and
the bottom of the foot, and there are methods for rating for those
conditions. As in the upper extremity, vascular lesions are rated
by a separate table.
ADMINISTRATIVE CONSIDERATIONS
The final decision about whether an individual is eligible for
benefits under a disability system is in all cases either legal or
administrative. Physicians performing disability evaluation must
recognize that they are simply providing information and opin-
ions upon which administrative or legal decisions can be made;
it is not unusual for medical perception of the amount of impair-
ment to translate financially into either considerably more or less
disability. Each piece of legislation concerning disability and
every administrative policy or contract includes very complex
methods of translating a physicians medical report into specific
numbers used to distribute benefits. The Social Security system
and many disability policies, for example, are all-or-none deci-
sions: An individual is declared either disabled or capable of
returning to work.
CONCLUSION
Rating physical impairment of the musculoskeletal system is an
entrenched part of the workers compensation system in the
United States as well as in many other third-party conflicts.
Assessing impairment and disability is an inexact science at best.
Because many findings require interpretation and the evaluator
must differentiate between those that are objective, subjective, or
subjective but able to be objectified, assessment requires the
knowledge, expertise, and skill of a physician. Because impair-
ment evaluation is rarely taught in medical school or residency,
it is unfortunately incumbent on the evaluator to undergo the
necessary training. It is unfair to all stakeholders not to provide
a fair and accurate rating.
The AMA guides attempt to provide a method whereby sev-
eral physicians can come to similar conclusions using the same
facts. Unfortunately, this is frequently not the case, because
many impairment ratings are done by physicians who do not
bother to understand the entire volume and the multiple ways in
which a patient can be evaluated. Obviously, these physicians see
a picture of the anatomic part to be rated and never stray from
that page. Physicians are also at cross-purposes with attorneys.
The evaluating physician must remember that the impairment
rating is only one part of an administrative process resulting in a
decision whether to award a monetary settlement to the claimant.
The adjudicatory process involves either an administrative law
judge or a jury. In addition, many times the evaluating physician
is required to give a deposition or even testify in court. Because
close adherence to the AMA guides increases the likelihood that
the rating will be given weight, it is important to use the prepared
report charts, especially in the upper extremity.
The administrative system believes that physicians have all the
answers when it comes to impairment, apportionment, and causa-
tion, and obviously this is not true. In doubtful cases, the physician
should not attempt to make estimates or statements that are not
justifiable. Apportioning in a patient who never had an impairment
rating before an injury may be impossible, and again this may be
more of an administrative decision than a medical one. The inde-
pendent physician should remain neutral and advocate neither for
the patient nor for the insurance company or attorney. Fair and
accurate impairment ratings are as much an obligation to physi-
cians as treatment itself, and we as independent physicians must
be as diligent in performing them as we are in caring for patients.
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A
Abduction, hip, 291292, 292f
Ability(ies)
defined, 398t
evaluation of, 395416
Accessory handles, 258, 259f
Accommodation of work populations,
process for, 195, 195f
Acetaminophen, for arthritis of knee, 304
Achilles tendon overuse injuries, diagnosis and
treatment of, 370371
Acromioclavicular joint
articulation of, 155
fracture-dislocations of, 189190
Active range of motion (AROM), neck injuries
in workers and, 55, 5758, 58f
Activities of daily living (ADLs)
joint forces during, hip and knee,
281284, 283f
in wrist and hand evaluation, 233
Activity ability, in disability evaluation,
411412
Acute herniated disk, 7577, 76f, 77t, 78f
treatment of, 77, 78f
Adaptation, workplace, 8793. See also
Workplace adaptation
Adduction, hip, 291292, 292f
Adhesive capsulitis, 190191
ADLs. See Activities of daily living (ADLs)
Adsons test, 65
Adsons maneuver, 65, 172
Aerobic capacity testing, FPE validity in,
404405
AFOs. See Ankle foot orthoses (AFOs)
Age
as factor in internal joint forces for hip and
knee, 277279, 278f
as factor in MSDs, 269
Age Discrimination Employment Act (1967), 400
Agency for Health Care Policy and Research
(AHCPR), 56, 411
AMA. See American Medical Association (AMA)
American Academy of Disability Evaluating
Physicians, 413
American Academy of Orthopaedic
Surgeons, 228
American College of Occupational and
Environmental Medicine, Occupational
Medicine Practice Guidelines of, 299, 301
American Heart Association, 401
American Medical Association (AMA),
115, 410
Guides to the Evaluation of Permanent Impairment
of, 412415
American National Standards Institute
(ANSI), 216
American Physical Therapy Association, 400
American Psychological Association, 400
American Society for the Surgery of the Hand,
228, 230
American Society of Hand Clinicians, 230
Americans with Disabilities Act, 400, 409
Amputation, foot, partial, in diabetics, 392
Analgesia/analgesics, opioid, for hip pain, 301
Analytic epidemiology, 59, 6f8f, 8t
case-control study, 7, 7f
cohort study, 67, 6f
cross-sectional study, 78, 8f, 8t
randomized trials, 89, 8f
Anatomic variation as factor in internal joint
forces for hip and knee, 279
Anatomic/biomechanical abnormalities,
sports-related foot and ankle
injuries due to, 334335, 335f
Anesthesia/anesthetics
local injection, in elbow evaluation, 180
in shoulder instability examination, 187188
Ankle, 329393. See also Foot and ankle
disorders; Foot and ankle injuries
arthrodesis of, indications for, 385
arthrology of, 342343
arthrosis of
after fracture, workplace adaptation of
workers with, 390
diagnosis and treatment of, 369370
biomechanical demands of, in workplace, 384
biomechanics of, 343345, 346f
calcaneocavus of, abnormal ROM of, after
foot and ankle injuries, 385
chronic pain of, diagnosis and treatment of,
368370
equinus of, after foot and ankle injuries,
384385
fractures of, workplace-related, occult fractures,
355356, 356f
impingement lesion of, anterolateral,
workplace-related, 355
instability of
after sprain, 354, 354f
chronic, 367
lateral, impingement syndrome of, diagnosis
and treatment of, 369
loose bodies in, diagnosis and treatment
of, 369
medial, burning pain around, case
study, 386
overuse injuries of, diagnosis and treatment of,
370372
AnkleContd
plantar flexion and dorsiflexion of,
limited ROM with, after foot
and ankle injuries, 385
ROM of, 345347, 346f
sprains of
workplace adaptation of workers with, 389
workplace-related, 353355, 354f, 355f
ankle instability after, 354, 354f
grading of, 353
impingement lesion, 355
osteochondral lesions of talus, 355, 355t
persistently painful, 353354
tear of peroneus longus or brevis tendon,
354355, 355f
treatment of, 353
tendon injuries around, diagnosis and
workplace-related injuries of, 352356
fractures, 352353, 352f
sprains, 353355, 354f, 355f. See also Ankle,
sprains of
Ankle foot orthoses (AFOs), 383, 386, 391, 392f
Ankle joint, 342
movement transfer of, 345
rotational axis of, 345
Ankle joint complex motion, 345347, 346f
restraints of, 347
rotational axis and movement transfer of ankle
joint, 345
ANSI. See American National Standards
Institute (ANSI)
Antalgic gait pattern, 290
Anterior atlantodens interval, 82
Anterior drawer test, 295296, 296f
Anterior instability, of shoulder, evaluation of,
171, 171f
Anterior talofibular ligament (ATFL),
function of, 367
Anthropometric considerations, in workplace
adaptation for shoulder disorders,
204206, 205f, 206f
Antidepressant(s), for low back pain, 131
Antifatigue mats
contaminants effects on, 319320
for jobs requiring prolonged standing,
319320
Anti-inflammatory drugs, nonsteroidal (NSAIDs)
for hip arthritis, 299
for low back pain, 129
Apley test, 295, 295f
Apple Computers QuickTime, 201
Apportionment, in disability evaluation, 412
Index
Arch(es), foot, 343, 344f
Arm rests, in workplace adaptation for shoulder
disorders, 207
AROM. See Active range of motion (AROM)
Arthritis
of hip, treatment of, 299, 301f
of knee, treatment of, 304305, 305f, 306f
of lower extremity, 270
rheumatoid. See Rheumatoid arthritis
Arthrodesis(es), indications for, 385
Arthrology, of foot and ankle, 342343
Arthroscopy
in hip evaluation, 297
in knee evaluation, 297
Arthrosis, ankle
after fracture, workplace adaptation of
workers with, 390
Articulation(s), elbow, 163164, 163f
ASO brace, 353
Assessment, defined, 398t
ATFL. See Anterior talofibular ligament (ATFL)
Athletes foot, 381
Atrophy
deltoid, 168, 168f
of fat pad, diagnosis and treatment of, 374375
shoulder-related, 168169, 168f
Avascular necrosis, of hip, treatment of, 301, 302f
Axial compression test, 64
B
Babinskis sign, 60, 64f
Back, lower, 95144
Back pain
problems related to
described, 97
disability due to, 103104, 104f
epidemiologic studies of, 9799, 98f
implications of, 104105
incidence of, 99100, 99f
occupational and other relevant
exposures, 9798
prevalence of, 99100, 99f
risk factors for, 100102
structural pathology and, 100101
tissue injury and, 100101
work-related, reporting of, 102103
Baltimore Therapeutic Equipment
Primus FPE, 402
Baltimore Therapeutic Equipment Work
Simulator, 403
Bankart procedure, for shoulder instability, 188
Barium swallow, in neck injury evaluation in
workers, 69
Belly press, 170
Bennett Hand-Tool Dexterity Test, 234
Best Evidence Synthesis on Traumatic Mild
Injury, 26
Biomechanic(s)
of cervical and thoracic spine, 4154. See also
Cervical spine; Thoracic spine
of elbow, 162166
of neck, 4142, 41f44f
of shoulder, 155162
Biopsychosocial model, of work-related MSDs,
1314, 14f
Black nail, 381
Blister(s)
of foot, 381
of toe, safety footwear and, case study,
388, 388f
Body link sizes, as fractions of total stature,
197, 197t
Body masses, for males and females ages 18 and
over, 197, 198t
Body segment distance, from proximal joint
center of gravity, 197, 197t
Body segment weights, as percentage of total
body mass, 197, 197t
Body supports, in workplace adaptation for
shoulder disorders, 207
Bone(s)
cuneiform, 341342, 341f
of foot, 341342, 341f
tarsal, of midfoot fractures,
Bone and Joint Decade (20002010)
initiative, 97
Bone scans, in neck injury evaluation
in workers, 69
Bouchards nodes, 245
Brace(s), ASO, 353
Brachial plexus, 59
Brachioradialis reflex, inverted, 62
Bristow procedure, for shoulder
instability, 188
Bureau of Labor Statistics, 309, 351
Bursitis
lower extremity, 269270
trochanteric, treatment of, 301
C
CAI. See Chronic ankle instability (CAI)
Calcaneofibular ligament (CFL),
function of, 367
Calcaneous, 341, 341f
abnormal ROM of, after foot and ankle
injuries, 385
fractures of
Callus(es), of foot, 380381
CAM walker boot, 358
Canon, W., 13
Capacity, defined, 398t, 402
Capsulitis, adhesive, 190191
Carpal ganglia, 246, 246f
Carpal joint, force through, 223224, 223f
Carpal tunnel syndrome (CTS), 211218,
238239
described, 238
diagnosis of, 238239
treatment of, 239
Carpal Tunnel Syndrome Questionnaire, 228
Carpet installation
clinical responses to, biomechanical basis for,
case study, 311314, 312f314f
stretcher adapter in, 318319
Carpet installers
injury/disease prevention plan for, 315319,
316f318f
lower extremity trauma in, case study,
311314, 312f314f
NIOSH ALert for, 318, 319
Carrying load
low back pain associated with, work
adaptations for, 138139, 140f, 141f
in workplace, 384
Cartesian coordinate system, 254, 254f
Case-control study, in analytic |
epidemiology, 7, 7f
Causalgia, 375
Causation, in disability evaluation, 412
CBT. See Cognitive behavioral therapy (CBT)
Cervical degenerative disk disease, 7779,
80f, 81f
spondylitic myelopathy, 7879, 80f, 81f
spondylosis, 7778
Cervical spine
biomechanics of, 4154
disorders of. See also specific disorders,
e.g., Neck sprain
acute herniated disk, 7577, 76f, 77t, 78f
cervical degenerative disk disease, 7779,
80f, 81f
hyperextension injuries, 8283
neck sprain, 75
rheumatoid arthritis, 79, 8182, 82f
spondylosis, 7778
treatment of, 7386
algorithm for, 8386, 84f, 85t
whiplash injury, 8283
lower, biomechanics of, 46, 49f53f, 53t,
54, 54t
upper, occiput/C2, biomechanics of, 42,
44f48f, 44t, 45t
CFL. See Calcaneofibular ligament (CFL)
Charcot deformity, 375
Charcot neuroarthropathy, in diabetics,
391392, 392f
Choparts joint, 342, 377
Chronic ankle instability (CAI), sports-related
foot and ankle injuries due to, 335
Chronic regional pain syndrome, workplace-
related, 365
Claims processor job, for identifying
and controlling shoulder and neck
stressors, sample documentation and
analysis of, 88t
Clavicle, fracture-dislocations of, 189
Clinical Guidelines for the Management of
Acute Low Back Pain, 14
Clonus, 60
Cochrane review of multidisciplinary
biopsychosocial rehabilitation, 129
Cognitive behavioral therapy (CBT), for NSLBP,
127f, 128
Cohort study, in analytic epidemiology,
67, 6f
Common peroneal nerve, entrapment
of, 376
Complex regional pain syndrome
(CRPS), 247
Index 418
Computed tomography (CT)
in elbow evaluation, 179, 180f
in low back pain evaluation, 119f, 120
in neck injury evaluation, 6768, 67f, 68f
in shoulder evaluation, 175
Concurrent validity, defined, 403t
Confidence limits, in statistical analysis, 910
Confounding, 56
defined, 5
Constraint(s)
of elbow, 164165
of glenohumeral joint, 158161, 160f
Construct validity, defined, 403t
Contaminant(s), impact on antifatigue properties
of floor mats, 319320
Content validity, defined, 403t
Copenhagen Neck Functional Disability
Scale, 66
Corns, 380
Corticosteroids, for low back pain, 131
Cox proportionate hazards model, 9
Crawford Small Parts Test, 234
Criterion validity, defined, 403t
Cross-sectional study, in analytic epidemiology,
78, 8f, 8t
Crouching, in workplace, 384
CRPS. See Complex regional pain syndrome
(CRPS)
Crush injury, of foot, workplace-related, 365
CT. See Computed tomography (CT)
CTS. See Carpal tunnel syndrome (CTS)
Cuboid, 341f, 342
Cumulative Load Theory, of musculoskeletal
injury causality, 135
Cuneiform bones, 341342, 341f
Cutting tools, 252253, 253f, 254t
Cyst(s)
mucous, of wrist and hand, 246247
retinacular, 246
D
DASH (disabilities of the arm, shoulder, and
hand) test, 228
de Quervain disease, 237, 237f, 245, 245f
Deep peroneal nerve, entrapment of, 376
Degenerative joint disease, of shoulder, 191
Deltoid atrophy, 168, 168f
Dermatome testing, in neck injury evaluation in
workers, 59, 59f
Descriptive epidemiology, 45
Dexterity, in wrist and hand evaluation,
233234, 233f, 234f
Diabetes mellitus, foot problems in workers
with, 391392, 391f, 392f
Diagnostic blocks about elbow, in elbow
evaluation, 180
Dictionary of Occupational Titles (DOT), of
U.S. Department of Labor, 399, 400t
Differential Fatigue Theory, of musculoskeletal
injury causality, 135
Digital flexor tendon sheath, 237, 238f
Disability(ies)
back painrelated, 103104, 104f
defined, 397
evaluation of. See Disability evaluation
low back painrelated, 136
Disability evaluation
ethics associated with, 409410
impairment determination in
AMA guides in
differences between fourth and f ifth
editions, 413
lower extremity impairments, 414415
pain, 413
spine impairments, 413414
upper extremity impairments, 414
principles of, 412415
rating of, AMA guides in, 413415
medical opinions required during, 410412
apportionment, 412
causation, 412
date of permanent and stationary
status, 410
diagnosis, 410411
ongoing and future medical care
requirements, 412
residual objective findings, 410
residual subjective complaints, 410
return-to-work determinations, 411
work and activity ability, 411412
for neck injuries in workers, 55, 55t
physicians role in, 409416
administrative considerations, 415
Disease stage, as factor in internal joint forces
for hip and knee, 279, 279f
DISI. See Dorsal intercalated segmental
instability (DISI)
Disk(s), herniated, acute, 7577, 76f, 77t, 78f
Disk degeneration
hereditary influences on, 101
occupational influences on, 101102
Diskcriminator, 231
Diskography, in low back pain evaluation, 122
Dislocation(s)
foot, workplace-related, 362364, 362f364f
of MTP joint, treatment of, 378
shoulder-related, 189190
subtalar joint, diagnosis and treatment
of, 372
Distal interphalangeal joint,
osteoarthritis of, 246
Distal radius fracture, 242243, 243f
Distraction test, 64
Dorsal intercalated segmental instability
(DISI), 224
Dose-response relationship, described, 87
DOT. See Dictionary of Occupational Titles
(DOT)
DOT Residual Functional Capacity battery,
403404
Down syndrome, 4
DRE method. See Diagnosis-related estimate
(DRE) method
Dropping sign, 170
duToit capsulorrhaphy procedure, for shoulder
instability, 188
Dynamic forces, 260262, 260f262f
Dynamic work, low back pain associated with,
work adaptations for, 138143, 139f142f
carrying, 138139, 140f, 141f
lifting and lowering, 139143, 141f, 142f
pushing and pulling, 138, 139f
Dynamometric devices, isokinetic and isoinertia,
in low back pain evaluation, 122
E
Economic issues, in low back pain, 114115
Edema
of lower leg, after foot and ankle injuries,
386387, 387f
in wrist and hand evaluation, 228229, 229f
Elbow
articulations of, 163164, 163f
anatomic considerations in, 162164,
163f, 164t
constraints, 164165
developments in, 165
future directions in, 165
kinematics, 164
kinetics, 165
disorders of, 149154. See also Elbow disorders
CT in, 179, 180f
diagnostic blocks in, 180
diagnostic testing in, 178180, 179f, 180f
EMG in, 179180
local anesthetic block in, 180
MRI in, 179
nerve conduction studies in, 179180
patient history in, 176177
physical examination in, 176f, 177178, 177f
radiography in, 178179, 179f
technetium bone scanning in, 180
muscles of, 164, 164t
stiffness of, 176
tennis, 149
resistant, 152
Elbow disorders, 149154
classification of, 149
entrapment neuropathies, 152, 177
epidemiology of, 149150, 150t
individual factors for, 151
in newspaper workers, 150, 150t
occupational risk groups for, 149150, 150t
pathomechanisms of, 151152
prevention of, 152
social factors for, 151
tendinopathy, 177
work-related factors for, 150151
Electrodiagnostic studies, in neck injury
evaluation in workers, 6971, 72t
Electromyography (EMG)
in elbow evaluation, 179180
in neck injury evaluation, 70
surface, in analysis of job task demands,
202203
Elevated arm stress test, 65
Index 419
Embase, 25
EMG. See Electromyography (EMG)
Entrapment neuropathies
about elbow, 177
common peroneal nerve, 376
deep peroneal nerve, 376
elbow and shoulder disorders and, 152
of foot and ankle, 375377
joggers foot, 377
Mortons neuroma, 377
posterior tibial nerve and branches, 376377
saphenous nerve, 377
superficial peroneal nerve, 376
sural nerve, 377
Valleix phenomenon, 375376
Epidemiologic concepts
analytic epidemiology, 59, 6f8f, 8t.
See also Analytic epidemiology
descriptive epidemiology, 45
measures of disorder frequency in, 34
in MSDs, 311
statistical issues, 911, 10f, 11t
Epidemiology
analytic, 59, 6f8f, 8t. See also Analytic
epidemiology
defined, 97
descriptive, 45
Equipment
described, 89
work-related, in analysis of job
task demands, 202
Ergonomics
for NSLBP, 128129
in shoulder disorder prevention, 162
Ergos Work Simulator, 402
Estimates, in statistical analysis, 910
Ethics, disability evaluation-related, 409410
European Guidelines 2005, 128, 129
Evaluation, defined, 398t
Event-based observations, time-based
observations vs., in analysis of job task
demands, 203
Evidence-based medicine (EBM) techniques, in
neck injury evaluation in workers, 56
Exercise, for NSLBP, 127f, 128
Exercise laboratories, of Veterans Affairs Health
Care System, 401
Exostosis, subungual, 381
Experimental study designs, clinical trials,
89, 8f
Exposure-response relationship, 195200, 195f,
196f, 197t, 198t, 199f, 200f, 200t
biomechanics of, 196197, 196f, 197t, 198t
described, 195196, 195f
limitations in, 197
worker capacity and, 198200, 199t, 200f,
200t, 201f
Extensor lag, defined, 294, 294f
External forces, acting on foot, 347
Extremity(ies), lower, 265416. See also Ankle;
Foot; Hip; Knee; Lower extremity
F
Face validity, defined, 403t
Fasciitis, plantar
Fat pad
atrophy of, diagnosis and treatment of,
374375
inflammation of, diagnosis and
treatment of, 375
Fatigue
MSDs due to, prevention of, 197198
muscular, as factor in elbow and shoulder
disorders, 152
work-related conditions affecting, 195200. See
also Exposure-response relationship
FCEs. See Functional capacity evaluations
(FCEs)
Federal Rules of Evidence, 56
Federal Uniform Guidelines of Employee
Selection Procedure (1978), 400
Finger(s)
joint injuries of, 242
trigger, 237238, 238f
Finger escape sign, 62
Finkelstein test, 245
Fissure(s), toenail-related, 382
Flexibility, lack of, sports-related foot and ankle
injuries due to, 335
Flexor hallucis longus tendon overuse problems,
Floor-to-waist lifting, in workplace, 384
Foot, 329393. See also Foot and ankle disorders;
Foot and ankle injuries
amputation of, partial, in diabetics, 392
anatomy of, 341342, 341f
arches of, 343, 344f
arthology of, 342343
athletes, 381
biomechanic(s) of, 343345, 346f
biomechanical demands of, in workplace, 384
bones of, 341342, 341f
external forces acting on, 347
fractures of, 356362, 357f359f, 361
calcaneus fractures, 356359, 357f, 358f
metatarsal fractures, 360360f
midfoot fractures, tarsal bones of, 360
phalangeal fractures, 361362
sesamoid fractures, 360361, 361f
talus fractures, 359360, 359f
ground reaction forces and pressure
distribution on, 344f, 348
internal forces acting on, 344f, 347348
joggers, 377
osteology of, 341342, 341f
plantar surface of, neuropathic ulcerations on,
in diabetics, 391, 391f
shoe selection considerations for,
348349, 348f
workplace-related injuries of, 356365
CRPS, 365
crush injuries, 365
dislocations, 362364, 362f364f
fractures, 356362, 357f359f, 361f. See also
Foot, fractures of
MTP joint injuries, 363364, 364f
FootContd
nerve injuries, 364
sprains, 362364, 362f364f
TMT joint injuries, 362363, 362f, 363f
Foot and ankle disorders, 329393. See also Foot
and ankle injuries
blisters, 381
calluses, 380381
corns, 380
ankle pain, chronic, 368370
ankle sprains, 367368
forefoot problems, 379380
fractures, 372374
midfoot injuries, 377379
nerve injuries, 375377
subtalar joint injuries, 372
tendon injuries around ankle, 370372
epidemiology of, 331339
military-related injuries, 332333, 333f
sports-related injuries, 333337, 334t, 335f,
336f. See also Sports, foot and ankle
injuries related to
studies of, methodology of, 331
work-related injuries, 331332
fungal infections, 381
skin conditions, 380381
toenail-related, 381382
warts, 381
workplace adaptation of workers with,
383393
ankle arthrosis after fracture, 390
ankle sprain, 389
for common conditions, 389393, 391f, 392f
diabetics, 391392, 391f, 392f
foot orthoses, 389
footwear, 383384, 383t, 387388, 387f, 388f
forefoot painrelated, 391
heel pain, 390
midfoot arthrosis and pain, 390391
tibialis posterior tendon insufficiency,
390, 391f
venous and lymphatic disorders, 392393
workplace-related, 351366. See also Ankle,
workplace-related injuries of; Foot,
workplace-related injuries of
approach to patient with, 351352
prevalence of, 351
return to work after, 365
types of, 352365
Foot and ankle injuries. See also Foot and ankle
disorders
deficits after, 384387, 385f, 387f
abnormal ROM, 384385, 385F
edema of lower leg, 386387, 387f
foot and ankle pain, 386
neurologic deficit, 385386
Foot and ankle movement, measurement
of, 343345. See also Ankle joint
complex motion
clinical and functional assessment in, 343
three-dimensional assessment in, 343345
Foot and ankle pain, after foot and ankle
injuries, 386
Index 420
Foot arch supports, 349
Foot orthoses (FOs), at workplace, 389
Footwear. See Shoe(s)
Force(s)
external, acting on foot, 347
internal, acting on foot, 344f, 347348
measurement of, in analysis of job task
demands, 202
prediction of, in analysis of job task demands,
203204
Forearm rests, in workplace adaptation for
Forefoot
painful, conditions of, workplace adaptation of
workers with, 391
problems related to, 379380
FOs. See Foot orthoses (FOs)
FPE. See Functional performance
evaluation (FPE)
Fracture(s)
about ankle, workplace-related, 352353, 352f
ankle arthrosis after, workplace adaptation of
workers with, 390
calcaneal
distal radius, 242243, 243f
foot and ankle, diagnosis and treatment of,
372373
heel spur, diagnosis and treatment of, 374
hip, treatment of, 299, 300f
Massoneuve, 353
metatarsal
workplace-related, 360360f
occult, of ankle, workplace-related,
355356, 356f
phalangeal, workplace-related, 361362
scaphoid, 243244, 243f
sesamoid, workplace-related, 360361, 361f
shoulder-related, 189190
stress, of foot and ankle, diagnosis and
talar
workplace-related, 359360, 359f
tarsal navicular, stress, 374
tibial pilon, 352
wrist and hand, 242244, 243f
distal radius, 242243, 243f
metacarpals, 244
phalanges, 244
scaphoid, 243244, 243f
Frozen shoulder, 190191
FSU. See Functional spinal unit (FSU)
Functional assessment, of wrist and hand,
232234
Functional Assessment Screening Test, 404
Functional capacity evaluations (FCEs),
397398. See also Functional performance
evaluation (FPE)
Functional performance evaluation (FPE),
397407
of aerobic capacity, reliability of, 402
characteristics of, 400406, 403t
Functional performance evaluation
(FPE)Contd
professional practice standards for, 400406,
403t
practicality, 405406
reliability, 401402
safety, 401
utility, 406
validity, 402405, 403t. See also Validity, of
FPE
purposes of, 398400, 400t
self-reported functioning, 399400
test components of, 399
validity of, legal constraints challenging, 400
of work-related activities, reliability of, 401402
work-related performance tests, 399
Functional performance testing, 397407. See also
Functional performance evaluation (FPE)
Functional Range of Motion Assembly Test, 402
Functional spinal unit (FSU), 107110, 108f,
109f, 109t
anterior portion of, 107, 108f, 109t
ligaments in, 109110
posterior portion of, 107109, 109f
Fungal infections
of foot, 381
of toenails, 382
F-wave response tests, 71, 72t
G
Gamekeepers thumb, 242, 242f
Ganglion(a)
retinacular, volar, 246
carpal ganglia, 246, 246f
mucous cysts, 246247
retinacular cysts, 246
ulnar tunnel, 239
Gender, as factor in internal joint forces for hip
and knee, 277279, 278f
Gibson Approach to FPE, 404
Glenohumeral joint, biomechanics of, 158162,
159f, 160f, 161t, 162f
animal models, 162
constraints, 158161, 160f
disability prevention through ergonomics, 162
kinematics, 158, 159f
kinetics, 161
mechanical properties of articular cartilage and
ligaments, 161162, 161t, 162f
Glenohumeral ligaments, 160161, 160f
Goniometer(s), in low back pain evaluation, 122
Grip and release test, 62
Guides to the Evaluation of Permanent Impairment,
of AMA, 412415
H
Hallux limitus, 385, 385f
Hallux rigidus, 379
Hallux seseamoid stress fractures, 373374
Hallux valgus, 379
Hammer toes, 379380
Hand, 209263. See also Wrist and hand
Hand tools
biomechanical aspects of, 249265
manual screwdrivers, 249251, 249f, 251f
Phillips head screws, 251f, 252, 252t
pliers and cutting tools, 252253, 253f, 254t
power tools, 249, 253262. See also Power
hand tools
recommendations, 263
screwdriver blades and screw heads, 251252,
251f, 252f, 252t
slotted screws, 251252, 252f, 252t
Torx head screws, 251f, 252, 252t
manual, 249
Hand-arm vibration syndrome, 213, 239240
Handle force model, dynamics of,
261262, 261f
Hawkins impingement test, 171
Hazard, defined, 9
Heel pain
Heel pain syndrome, diagnosis and
treatment of, 374
Heel spur(s), diagnosis and treatment of, 374
Heel spur fracture, diagnosis and treatment of, 374
Hematoma(s), subungual, 381
Heredity, as factor in lower extremity
osteoarthritis, 270
Herniated disk, acute, 7577, 76f, 77t, 78f
Herniation(s), soft disk, types of, 75, 76f
Hindfoot, stress fracture of, 373
Hip, 267327
abduction of, 291292, 292f
adduction of, 291292, 292f
arthritis of, treatment of, 299, 301f
avascular necrosis of, treatment of, 301, 302f
kinematics, 273274, 274t
kinetics, 274277, 275f
reducing internal joint load, 277285,
278f285f. See also Internal joint forces,
on hip and knee
clinical evaluation of, 289297
CT in, 296
imaging in, 296
MRI in, 296, 301
patient history in, 289, 289t
physical examination in, 289292, 290f292f
radiography in, 296, 299, 300f
fractures of, treatment of, 299, 300f
kinematics of, 273274, 274t
kinetics of, 274277, 275f
osteonecrosis of, treatment of, 301, 302f
pain of
severe, treatment of, 299, 301
treatment of, 301
range of motion of, 290291, 291f
rotation of, 290291, 291f
sprains and strains of, treatment of, 301
trochanteric bursitis of, treatment of, 301
work-related problems of, treatment of,
299301, 300f302f
Index 421
Hip extension, 291, 292f
Hippocratic Oath, 409
Hoffmans sign, 60, 64f
Holding work, low back pain associated with,
work adaptations for, 137, 138f
Homer syndrome, 82
Horn blowers sign, 170, 170f
Humerus, proximal, fracture-dislocations of, 190
Hyperextension injuries, 8283
treatment of, 83
Hypothenar hammer syndrome, 213
I
Imaging
Impairment evaluation, for neck injuries in
workers, 55
Impingement lesion, anterolateral, of ankle,
Impingement syndrome, 185187
of lateral ankle, diagnosis and treatment
of, 369
Incidence, defined, 25
Incidence rate, defined, 4
Industrial back injury incident reports and
claims filing, 102103
Industrial Commission of Ohio, 311
Inflammation, of fat pad, diagnosis and
treatment of, 375
Information processing, in wrist and hand
evaluation, 232233
Ingrown toenails, 381
In-line power drivers, 256f, 257258
Instability
anterior, of shoulder, 171, 171f
shoulder, 185189. See also Shoulder(s),
instability of
Internal joint forces
on foot, 344f, 347348
on hip and knee, 277285, 278f285f
during ADLs, 281284, 283f
squatting, 281283, 283f
stair climbing, 283284
walking, 283284
factors affecting, 277279, 278f, 279f
reduction of, 280281, 280f282f
lever arm reduction in, 280, 280f, 281f
synergic movement and muscular
coactivation in, 280281, 282f
task variables in, 284285, 285f
in vivo direct measurement of,
hip and knee, 277
International Classification of Diseases, 149, 411
International Standards Organization
(ISO), 216
Interphalangeal joint, proximal, osteoarthritis of,
245246
Interview(s)
patient, in neck injury evaluation in workers, 56
worker and supervisor, 202
Ischemia, local, 152
Isernhagen Work Systems FCE, 404
Isernhagen Work Systems FPE, 402
ISO. See International Standards
Organization (ISO)
Israeli Defense Forces Medical Corps, 332
J
Job documentation, 200
Job rotation, 137
Job stresses, physical, in analysis of job task
demands, 202204, 203f. See also Physical
job stresses, in analysis of job task
demands
Job task demands
analysis of, 200204, 202t
physical job stresses in, 202204, 203f. See
also Physical job stresses, in analysis of
job task demands
interviews, 202
job documentation, 200
measurements of work station and
equipment, 202
observations, 200201
video recordings, 201202
Joggers foot, 377
Joint(s)
foot and ankle, 342343. See also specific joint
wrist and hand, constraint and stability of, 219
Joint forces, wrist and hand, 221223, 223f
Joint loads, estimation of, 198, 200
K
Kienbck disease, 223
Kinematics
elbow, 164
glenohumeral, 158, 159f
hip, 273274, 274t
knee, 273, 273t
spine, 110, 110f, 111f
Kinetics
elbow, 165
glenohumeral, 161
hip and knee, 274277, 275f
spine, 110112, 111f, 112f
Knee, 267327
analytical joint models of, 275277, 275f, 276f
kinematics, 273, 273t
kinetics, 274277, 275f
reducing internal joint load, 277285,
278f285f. See also Internal joint forces,
on hip and knee
arthroscopy in, 297
MRI in, 297
physical examination in, 292296, 292f296f
radiography in, 296
jobs requiring use of, injury/disease prevention
plan for, 315319, 316f318f
joint forces on, in vivo direct measurement
of, 277
kinematics of, 273, 273t
kinetics of, 274277, 275f
KneeContd
treatment of, 304305, 305f, 306f
pain of
anterior, treatment of, 306
nonspecific, treatment of, 306
sprains of, treatment of, 303304, 303f, 304f
tendinitis of, treatment of, 305306
varus/valgus deformity of, 292, 292f
work-related problems of, treatment of,
301306, 303f306f
Knee injuries
acute, workplace-related, chronic pain,
discomfort, and work restrictions due to,
case study, 320325, 321t, 324t
ligamentous, treatment of, 303304, 303f, 304f
meniscal, treatment of, 301303, 303f
Knee joint stability, testing of, 295296, 295f,
296f
Kneeling, in workplace, 384
L
Laboratory studies, in neck injury evaluation in
workers, 71
Lachman test, 295296, 296f
Lateral cord of brachial plexus, 59
Lateral elbow syndrome, 149
Lateral humeral epicondylalgia, 149
Leg(s), lower, edema of, after foot and ankle
injuries, 386387, 387f
Legend of variable notation, 255t
Lesion(s). See specific types, e.g., Osteochondral
lesions
Lhermittes sign, 60, 81
Liberty Mutual Insurance Company, 136
Liberty Mutual Insurance Company database, 100
Lidocaine injection tests, in shoulder evaluation,
175, 176f
Lifting, floor-to-waist, in workplace, 384
Lifting and lowering, low back pain associated
with, work adaptations for, 139143,
141f, 142f
Ligament(s)
glenohumeral, 160161, 160f
spine, 109110
wrist and hand, constraint of, 219
Lisfrancs joint, 342
injuries of, diagnosis and treatment of, 378
Local anesthetic injection, in elbow
evaluation, 180
Local ischemia, 152
Loge of Guyon, 239
Long-tract signs, in neck injury evaluation in
workers, 60, 62, 64f, 65f
Low back, 95144
Low back pain
causes of, 135136
theories of, 135136
vs. exacerbation, 9899
chronic, treatment of
manipulation in, 129
multimodal programs in, 129, 130t
control of, 135136
costs related to, 136
differential diagnosis of, 122123
Index 422
Low back painContd
disabilities due to, 136
duration of, treatment goals related to, 126
evaluation of
blue flags in, 115
CT in, 119f, 120
diskography in, 122
EMG in, 122
initial, 113124
laboratory studies in, 122
mechanical testing in, 122
MRI in, 120121, 120f, 121f
myelography in, 117f, 120
physical examination in, 115118,
116f118f
patient on side, 118
patient prone, 118
patient sitting, 116, 116f
patient standing, 115116
patient supine, 116118, 117f, 118f
radiography in, 119120
radionuclide bone scan in, 121
red flags in, 113115, 113t
specialized examinations in, 117f121f,
119122
ultrasonography in, 121122
yellow flags in, 114115
nature of, 135
nonspecific, 125
potentially serious conditions related to,
red flags for, 113115, 113t
prevalence of, 136
problems related to, extent of, 136
psychosocial and economic issues
associated with, 114
specific, 125
antidepressants in, 131
complications of, 132
corticosteroids in, 131
models for, 125
muscle relaxants in, 129, 131
NSAIDs in, 129
occupational health guidelines in, 125
opioids in, 131
patient expectations in, 125126
surgical, 131132
workplace adaptation for, 135144
dynamic work, 138143, 139f142f.
See also Dynamic work, low back
pain associated with, work
adaptations for
holding work, 137, 138f
seated work, 137
static work, 136137
Lower back, 95144. See also under Low back
pain
Lower extremity, 265416. See also Ankle; Foot;
Hip; Knee
epidemiology of, 269272, 269t, 270t
definitions associated with, 269
occupational illness, 269
occupational injuries, 269
Lower extremity disorders
age-related, 269
adaptations recommended for, 315325,
316f318f, 321t, 324t
in carpet installers, 311314, 312f314f
injury/disease prevention plan for,
315319, 316f318f
industry-specific data, 309
knee injury, chronic pain, discomfort, and
work restrictions due to, case study,
320325, 321t, 324t
prevalence of, 309
vascular problems, 314315
Lowering, low back pain associated with,
work adaptations for, 139143,
141f, 142f
Lunotriquetral interval injury, 241
Lymphatic disorders, foot and anklerelated,
workplace adaptation of workers with,
392393
M
Magnetic resonance imaging (MRI)
in hip evaluation, 296, 301
in low back pain evaluation, 120121,
120f, 121f
in neck injury evaluation, 68, 68f70f
in shoulder evaluation, 174175, 175f
Maine-Seattle back pain disability
questionnaire, 9
Manipulation, for chronic low back pain, 129
Manual hand tools, 249253, 249f, 251f253f,
252t, 254t
Manual screwdrivers, 249251, 249f, 251f
handle diameter of, 250251, 251f
handle length of, 249250, 249f
Massoneuve fractures, 353
Mat(s), antifatigue
contaminants effects on, 319320
for jobs requiring prolonged standing,
319320
Maximum voluntary contraction (MVC), 150
McGill Pain Profile, 227
McGill Pain Questionnaire, 232
McGregor line, 82
McMurray test, 294, 294f
Mechanical assists, in workplace adaptation for
Mechanical testing, in low back pain
evaluation, 122
Medial cord of brachial plexus, 59
Medical history, as factor in internal joint
forces for hip and knee, 279, 279f
Medical Outcomes Study, 66
MEDLINE, 25
Meniscal injuries, treatment of,
301303, 303f
Metabolic equivalent intensity levels, 399
Metacarpal(s), fractures of, 244
Metatarsal(s), 341f, 342
Metatarsal fractures
stress fractures, 373
workplace-related, 360360f
Metatarsalgia, 380
Metatarsophalangeal (MTP) joint, 342343
Metatarsophalangeal (MTP) joint injuries
sprains and dislocations, treatment of, 378
Michigan Hand Questionnaire, 228
Midfoot, arthrosis and pain of, workplace
adaptation of workers with, 390391
Midfoot injuries, 377379
Midtarsal sprains, 377378
Military shoes, at workplace, 388
Military-related foot and ankle injuries,
332333, 333f
Minnesota Manual Dexterity Test, 234, 234f
Moberg Pick Up test, 233
Moment(s), reduction of, 280281, 280f282f
Monofilament(s), Semms-Weinstein, 231, 414
Mortons neuroma, 377
MOS 36-Item Short Form Health Survey
(SF-36), 66
Motion, wrist and hand, 219220
Motor strength examination, in neck
injury evaluation in workers,
5960, 60f62f, 60t
MRI. See Magnetic resonance imaging (MRI)
MSDs. See Musculoskeletal disorders (MSDs)
MTP joint injuries. See Metatarsophalangeal
(MTP) joint injuries
Mucous cysts, of wrist and hand, 246247
Multivariate Interaction Theory, of
musculoskeletal injury causality, 136
Muscle(s)
elbow, 164, 164t
mechanical failure of, 152
nerve and main root supply of, 71, 72t
shoulder, 157158, 157t
Muscle grading, 170, 170t
Muscle performance testing, in wrist and hand
evaluation, 229230, 230f
Muscle relaxants, for low back pain, 129, 131
Muscular fatigue, as factor in elbow and
Musculoskeletal disorders (MSDs)
age as factor in, 269
epidemiologic concepts in, 311. See also
Epidemiologic concepts
frequency of, measures of, 34
of hand and wrist, 211218, 211f, 212f, 214t,
215t. See also Wrist and hand disorders
localized fatigue and, prevention of, 197198
of lower extremity, workplace-related, 309314,
310f, 312f314f
of neck, in workers, evaluation of, 5572.
See also Neck, evaluation of
occupational, defined, 269
psychologic and psychosocial factors
associated with, 1415
psychosocial aspects of, 1318. See also
Psychosocial factors, MSDs and
psychosocial interventions for, 1617, 17f
Index 423
Musculoskeletal disorders (MSDs)Contd
risk factors for, work-related conditions
affecting, 195200. See also Exposure-
response relationship
in workers, neck pain associated with, 2540.
See also Neck pain, in workers,
epidemiology of
Musculoskeletal pain, prevalence of, 397
MVC. See Maximum voluntary contraction
(MVC)
%MVC. See Percentages of maximum voluntary
contraction (%MVC)
Myelography
in low back pain evaluation, 117f, 120
in neck injury evaluation, 6869, 71f
Myelopathy, spondylosis with, 7879, 80f, 81f
Myeloradiculopathy, 78
N
National Academy of Sciences, 213
National Center for Health Statistics, statures
and body masses for males and females
ages 18 and over, 197, 198t
Health (NIOSH), 139
Health (NIOSH) Report on
Musculoskeletal Disorders (MSDs) and
Workplace Factors, 397
Navicular, 341, 341f
Neck, 2393
anatomy of, 7375, 74f, 75f
biomechanics of, 4142, 41f44f
disorders of, workplace adaptation to, 8793.
See also Workplace adaptation, to MSDs,
neck-related disorders
evaluation of, 5572
AROM in, 5758, 58f
barium swallow in, 69
bone scans in, 69
CT in, 6768, 67f, 68f
disability examination in, 55, 55t
electrodiagnostic studies in, 6971, 72t
EMG in, 70
evidence-based medicine in, 56
imaging studies of spine in, 6669, 66f71f
impact-related, 6566, 66t
impairment evaluation in, 55
laboratory screening in, 71
MRI in, 68, 68f70f
myelography in, 6869, 71f
nerve conduction studies in, 71, 72t
neurologic examination in, 5965, 59f65f,
60t, 63t
long-tract signs, 60, 62, 64f, 65f
motor strength examination, 5960,
60f62f, 60t
reflex examination, 60, 62, 63f65f, 63t
sensory examination and dermatome
testing, 59, 59f
specialized physical tests, 6465, 65f
palpation in, 59
patient interview in, 56
NeckContd
physical examination in, 5759, 58f
PROM in, 58
radiography in, 6667, 66f, 67f
red flags in, 57, 57t
ROM in, 5759, 58f
Spurlings test in, 59
SSEPs in, 71
standard examination in, 55
MSDs of, in workers, evaluation of, 5572.
See also Neck, evaluation of
Neck Disability Index, 66
Neck pain
anatomy related to, 7375, 74f, 75f
causes of, 73, 73t
defined, 25
factors associated with, 27, 28t, 29
in workers
epidemiology of, review of, 2540
article selection in, 26
critical review of literature in, 26
data synthesis in, 26
literature search in, 2526
methods in, 2526
purpose of, 25
relevance of, 35
results of, 2635, 27f, 28t, 30t34t
selection and critical appraisal of articles
in, 2627, 27f
incidence of, 29, 30t31t
prevalence of, 27, 28t
risk factors for, 29, 30t31t
specific occupational groups, 29,
32t34t, 35
factors associated with, 29, 32t34t
incidence of, 29, 35, 36t37t
prevalence of, 29, 32t34t
risk factors for, 35, 36t37t
Neck Pain and Disability Scale, 66
Neck sprain, 74f, 75, 75f
prognosis for patients with, 75
treatment of, 75
Neck stressors, identification and control of,
sample documentation and analysis of
claims processor job in, 88t
Neck-related pain syndromes, causes of, 73, 73t
Neer impingement sign, 171, 171f
Neer procedure, for shoulder instability, 188
Nerve(s). See specific nerve, e.g., Saphenous nerve
Nerve conduction studies
in neck injury evaluation, 71, 72t
Nerve entrapments, lower extremity, 270
Nerve injuries
degrees of, 375
of foot and ankle, 375377
entrapment neuropathies, 375377
Neural network technique analysis of
motion patterns, in low back pain
evaluation, 122
Neuroarthropathy, Charcot, in diabetics,
391392, 392f
Neurologic deficits, after foot and
ankle injuries, 385386
Neurologic examination, in neck injury
evaluation in workers, 5965, 59f65f,
60t, 63t. See also Neck, evaluation of,
neurologic examination in
Neuroma(s), Mortons, 377
Neuropathic ulcerations, on plantar surface of
foot in diabetics, 391, 391f
New Zealand Guidelines, 14
Newspaper workers, elbow problems in,
150, 150t
Newtons Third Law, 196, 196f
NHANES I study, 270, 271
Nine Hole Peg Test, 233, 233f, 234
NIOSH. See National Institute for Occupational
Safety and Health (NIOSH)
NIOSH Alert, for carpet installers, 318, 319
Nonspecific low back pain (NSLBP), 125
acute
prognosis of, 126
self-care for, 126
treatment of, evidence for, 126
natural history of, 126
recurrence of, 126
subacute, treatment of
blue flags in, 127
interventions in, 127129, 127f
yellow flags in, 127
CBT in, 127f, 128
combination therapy in, 128
ergonomic intervention in, 128129
exercise in, 127f, 128
Nordic Health Questionnaire, 203
Northwick Park Neck Pain Questionnaire, 66
NSAIDs. See Anti-inflammatory drugs,
nonsteroidal (NSAIDs)
NSLBP. See Nonspecific low back pain (NSLBP)
O
Observation(s), of workers performances,
200201
Occlusion of superficial palmar branch of ulnar
artery, 213
Occult fractures, of ankle, workplace-related,
355356, 356f
Occupational illness. See also specific illness
defined, 269
Occupational injuries, defined, 269
Occupational Medicine Practice Guidelines, of
American College of Occupational and
Environmental Medicine, 299, 301
Occupational MSDs, defined, 269
Occupational Safety and Health Administration
(OSHA), 3, 4, 211, 411
OConnor Finger Dexterity Test, 233234
OConnor Tweezer Dexterity Test, 233, 234
Official Disability Guidelines, 411
O*NET, of U.S. Department of Labor, 234
Opioid(s)
for hip pain, 301
for low back pain, 131
Oppenheims sign, 60
Index 424
Orthosis(es)
ankle foot, 383, 386, 391, 392f
cervical (Philadelphia collar), 82
foot, at workplace, 389
sports-related foot and ankle injuries due to,
336337, 336f
supramalleolar, UCBL, 390, 391f
OSHA. See Occupational Safety and Health
Administration (OSHA)
Osteoarthritis
hip, 270271
imaging of, 296
knee, 271
treatment of, 304305, 305f, 306f
lower extremity, 270271, 270t
heredity as factor in, 270
wrist and hand, 213, 244246, 244f, 245f
Osteochondral lesions, of talus
workplace-related, 355, 355t
Osteonecrosis, of hip, treatment of, 301, 302f
Oswestry, 9
Overexertion theory, of musculoskeletal injury
causality, 135
Overuse injuries, ankle-related, diagnosis and
P
Pain
anterior knee, treatment of, 306
back. See Back pain
foot and ankle, after foot and ankle injuries, 386
heel
low back. See Low back pain
musculoskeletal, prevalence of, 397
neck, in workers, epidemiology of, 2540.
See also Neck pain, in workers,
epidemiology of
patellofemoral, treatment of, 306
wrist and hand, 232
Painful arc, 171
Passive range of motion (PROM), in neck injury
evaluation in workers, 58
Patellofemoral pain, treatment of, 306
Patient Specific Functional Scale, 66
Patient-rated Wrist Evaluation Questionnaire, 228
Pectoralis reflex, 62, 65f
Percentages of maximum voluntary
contraction (%MVC), 198
Performance, defined, 398t
Performance areas, defined, 398t
Peroneal nerve
common, entrapment of, 376
deep, entrapment of, 376
superficial, entrapment of, 376
Peroneal tendon injuries, diagnosis and
treatment of, 371
Peroneus brevis tendon, tear of, workplace-
related, 354355, 355f
Peroneus longus tendon, tear of, workplace-
related, 354355, 355f
Phalangeal fractures, workplace-related, 361362
Phalanges, 341f, 342
fractures of, 244
Phalens test, 239
Phillips head screws, 251f, 252, 252t
Physical capacity evaluation, in wrist and hand
evaluation, 234
Physical job stresses, in analysis of job task
demands, 202204, 203f
event-based vs. time-based observations, 203
measurement of posture and force, 202
prediction of posture and forces in, 203204
psychophysical responses, 203, 203f
surface EMG, 202203
Physical Work Performance Evaluation, 402
Physician(s), role in disability evaluation,
409416
Pistol-grip power drivers, 255257,
256f, 257f, 257t
Plain radiographs. See Radiography
Plantar fascia rupture, diagnosis and
treatment of, 374
Plantar fasciitis
Playing surfaces, sports-related foot and ankle
Plier(s), 252253, 253f, 254t
Popeye muscle, 172
Posterior atlantodens interval, 82
Posterior cord of brachial plexus, 59
Posterior talofibular ligament, function of, 367
Posterior tibial nerve, entrapment of, 376377
Posttraumatic injury, wrist and hand, 224, 224f
Posture
measurement of, in analysis of job task
demands, 202
prediction of, in analysis of job task demands,
203204
Power hand tools, 249, 253262
accessory handles and torque reaction arms,
258, 259f
dynamic forces with, 260262, 260f262f
handle force model, dynamics of, 261262, 261f
in-line power drivers, 256f, 257258
pistol-grip power drivers, 255257,
256f, 257f, 257t
right-angle power drivers, 254f, 257, 258f
static forces with, 254258, 254f, 255t,
256f258f, 257t
tool counterbalancers, 259260
tool torque buildup model, 260f, 2602261
Practicality, of FPE, 405406
Predictive validity, defined, 403t
Prevalence, defined, 25
Prevalence rate, defined, 4
Preventing Knee Injuries and Disorders in
Carpet Layers, 318
Prognostic study, in analytic epidemiology,
67, 6f
PROM. See Passive range of motion (PROM)
Pronator reflex, 64
Proximal humerus, fracture-dislocations of, 190
Proximal interphalangeal joint, osteoarthritis of,
245246
Psychologic factors, musculoskeletal disorders
and, 1415
Psychophysical responses, in analysis of job task
demands, 203, 203f
Psychosocial factors
in low back pain, 114115
MSDs and, 1415
relationship between, 1516
work-related, 1318
biopsychosocial model, 1314, 14f
described, 1516
evidence for, 1718, 17f
Psychosocial interventions, for MSDs,
1617, 17f
Pulling, low back pain associated with, work
adaptations for, 138, 139f
Purdue Pegboard Test, 233, 234, 234f
Pushing and pulling, low back pain associated
with, work adaptations for, 138, 139f
Putti-Platt procedure, for shoulder
instability, 188
Q
Q-angle, 279
Quebec Back Pain Disability Scale, 9
Quebec Task Force classification, 122
Quebec Task Force on Whiplash-Associated
Disorders, 26
QuickTime, 201
R
Radial tunnel syndrome, 152
Radiograph(s), in neck injury evaluation in
workers, 6667, 66f, 67f
Radiography
in elbow evaluation, 178179, 179f
in hip evaluation, 296, 299, 300f
in shoulder evaluation, 172174, 173f, 174f
Radiohumeral joint, articulation of, 164
Radionuclide bone scan, in low back pain
evaluation, 121
Radioulnar joint, articulation of, 164
Ranawat measurement, 82
Randomized control trials, in analytic
epidemiology, 89, 8f
Range of motion (ROM)
abnormal, after foot and ankle injuries,
384385, 385F
ankle plantar flexion and dorsiflexion, 385
calcaneocavus, 385
equinus of ankle, 384385
hallux limitus, 385, 385f
ankle, 345347, 346f
hip, 290291, 291f
knee, 294, 294f
in neck injury evaluation in workers, 55,
5759, 58f
wrist and hand, 228
Rate(s), defined, 34
Index 425
Ratio(s), defined, 34
Redlund-Johnell measurement, 82, 82f
Reflex examination, in neck injury evaluation
in workers, 60, 62, 63f65f, 63t
Reflex sympathetic dystrophy, 375
Relative risk, 9
Reliability, of FPE, 401402
Relocation test, 171, 171f
Repetition strain injury, 149
Repetitive hand transfer task, work elements,
locations, and loads for, 198, 200t
Repetitive motion disorders, 211, 212f
Resistant tennis elbow, 152
Retinacular cysts, wrist and hand, 246
Retinacular ganglia, volar, 246
Return-to-work determinations,
in disability evaluation, 411
Rheumatic diseases, lower extremity, 270
Rheumatism, lower extremity, 270
Rheumatoid arthritis, 79, 8182, 82f
hip, imaging of, 296
treatment of, 82
Right-angle power drivers, 254f, 257, 258f
Risk factors, defined, 25
Rocker-sole footwear, 385, 385f
Roland-Morris disability questionnaire, 9, 129
ROM. See Range of motion (ROM)
Rotation, hip, 290291, 291f
Rotator cuff, evaluation of, 168f, 170
Rotator cuff disease
anatomy and function in, 181182
classification of injury in, 182
clinical presentation of, 182185
differential diagnosis of, 182183
physical examination in, 182
goals in, 183
methods of, 183
nonoperative, 183
operative, 183184
postoperative care, 184185
S
Safety, of FPE, 401
Safety shoes, at workplace, 387388, 387f, 388f
Saphenous nerve, entrapment of, 377
Scaphoid fracture, 243244, 243f
Scaphoid trapezium and trapezoid
(STT) joint, 219
Scapholunate interval injury, 240241, 240f
Scapulohumeral reflex, 62
Screening, defined, 398t
Screw(s)
Phillips head, 251f, 252, 252t
slotted, 251252, 252f, 252t
Torx head, 251f, 252, 252t
Screw heads, 251252, 251f, 252f, 252t
Seated work, low back pain associated with,
work adaptations for, 137
Self-care, for acute NSLBP, 126
Semms-Weinstein monofilament(s), 414
Semms-Weinstein monofilament testing, 231
Sensation, in wrist and hand evaluation,
230232, 231f, 232f
Sensory examination, in neck injury evaluation
in workers, 59, 59f
Sesamoid(s), problems related to, 380
Sesamoid fractures, workplace-related,
360361, 361f
Shoe(s)
function of, 348, 348f
military, at workplace, 388
modifications for, for workers with foot and
ankle disorders, 383384, 383t
safety, at workplace, 387388, 387f, 388f
selection of, considerations in, 348349
steel-shank, 385
at workplace, 387388, 387f, 388f
for female workers, 388
military shoes, 388
safety shoes, 387388, 387f, 388f
Shoe inserts, 349
Shoe inserts/insoles, for jobs requiring
prolonged walking, 320
Shoe wear and orthoses, sports-related foot and
ankle injuries due to, 336337, 336f
Shoulder(s)
articulations of, 155157, 156f, 157f
anatomic considerations, 155158,
156f, 157f, 157t
bones of, 155, 156f
degenerative joint disease of, 191
disorders of, 149154. See also Shoulder
disorders
CT in, 175
diagnostic testing in, 172176, 173f176f
EMG in, 176
lidocaine injection tests in, 175, 176f
MRI in, 174175, 175f
nerve conduction studies in, 176
physical examination in, 167172, 168f172f,
168t, 170t
radiography in, 172174, 173f, 174f
technetium bone scanning in, 176
fractures and dislocations about, 189190
frozen, 190191
instability of, 185189
described, 185
evaluation of, 171, 171f
anesthesia in, 187188
impingement syndrome, 185187
treatment of, surgical procedures, 188189
joint capsule of, 160
muscles of, 157158, 157t
Shoulder disorders, 149154. See also specific types,
e.g., Rotator cuff disease
entrapment and, 152
individual factors for, 151
muscular fatigue and, 152
occupational risk groups for, 149150
pathomechanisms of, 151152
prevention of, 152
Shoulder disordersContd
ergonomics in, 162
social factors for, 151
treatment of, 181193. See also specific disorders,
e.g., Rotator cuff disease, treatment of
rotator cuff disease, 181185
shoulder instability, 185189. See also
Shoulder(s), instability of
workplace adaptation for, 195208
anthropometric considerations, 204206,
205f, 206f
arm rests, 207
body supports, 207
evaluation of, 207
exposure-response relationship, 195200. See
also Exposure-response relationship
forearm rests, 207
job task demands, analysis of, 200204, 202t.
See also Job task demands
mechanical assists, 206207
placement of work objects, 197t, 198t,
202t, 204
tool weight control, 206
worker fitness and weight, 207
work-related factors for, 150151
Shoulder joint, static stabilizers of,
158160, 160f
Shoulder stressors, identification and
control of, sample documentation
and analysis of claims processor
job in, 88t
Sinus tarsi syndrome, diagnosis and
treatment of, 369
Skiers thumb, 242, 242f
Skin disorders, foot-related, 380381
SLBP. See Specific low back pain (SLBP)
Slotted screws, 251252, 252f, 252t
Soccer toe, 381
Social Security, 409
Soft disk herniations, types of, 75, 76f
Somatosensory evoked potentials (SSEPs), in
neck injury evaluation in workers, 71
Spatial motion, 158, 159f
Specific low back pain (SLBP), 125
Speeds test, 172, 182
Spine
cervical. See Cervical spine
clinical biomechanics of, 107112
FSU, 107110, 108f, 109f, 109t.
See also Functional spinal unit (FSU)
kinematics, 110, 110f, 111f
kinetics, 110112, 111f, 112f
disorders of
back pain related to, 100101
imaging studies of, in neck injury
evaluation in workers, 6669,
66f71f
MSDs of, 22144
thoracic, biomechanics of, 4154
Spondylosis, 7778
with myelopathy, 7879, 80f, 81f
treatment of, 79
treatment of, 78
Index 426
Sports, foot and ankle injuries related to
causes of, 333337, 334t, 335f, 336f
anatomic/biomechanical abnormalities,
334335, 335f
lack of flexibility, 335
lack of stability, 335
lack of strength, 335
playing surfaces, 337
shoe wear and orthoses, 336337, 336f
epidemiology of, 333, 334t
prevention of, 337
Sprain(s)
ankle
foot, workplace-related, 362364, 362f364f
hip, treatment of, 301
knee, treatment of, 303304, 303f, 304f
midtarsal, 377378
of MTP joint, treatment of, 378
neck. See Neck sprain
wrist and hand, 240242, 240f242f
Spur(s), heel, diagnosis and treatment of, 374
Spurlings sign, 64, 65f
Spurlings test, in neck injury evaluation in
workers, 59
Squatting, during ADLs, joint forces and,
281283, 283f
SSEPs. See Somatosensory evoked potentials
(SSEPs)
Stability, lack of, sports-related foot and ankle
Stability testing, of elbow, 178
Stair climbing, during ADLs, joint forces and,
283284
Standard error (SE), 9
Standing, prolonged
antifatigue mats for jobs requiring, 319320
physiology/biomechanics of, 315
Static forces, with power hand tools, 254258,
254f, 255t, 256f258f, 257t
Static work, 136137
Statistical analysis, 911, 10f, 11t
estimates and confidence limits in, 910
methods of, 9, 10f
statistical hypothesis testing in, 10
statistical power and sample size in,
1011, 11t
Statistical hypothesis testing, 10
Statistical power and sample size, 1011, 11t
Stature(s), for males and females ages 18 and
over, 197, 198t
Steel-shank footwear, 385
Stener lesion, 242
Sternoclavicular joint
articulation of, 155
fracture-dislocations of, 189
Stiffness, elbow-related, 176
Straight leg raise, 290
Strain(s), hip, treatment of, 301
Strength
lack of, sports-related foot and ankle injuries
due to, 335
wrist and hand, 220
Stress fractures, of foot and ankle, diagnosis and
Stressor(s)
job-related, physical, in analysis of job task
demands, 202204, 203f. See also Physical
job stresses, in analysis of job task demands
neck and shoulder, identification and control
of, sample documentation and analysis
of claims processor job in, 88t
Stretcher adapter, in carpet installation,
318319
Subtalar joint, 342
Subtalar joint dislocations, diagnosis and
treatment of, 372
Subtalar joint injuries, diagnosis and
treatment of, 372
Subungual exostosis, 381
Subungual hematomas, 381
Superficial peroneal nerve, entrapment of, 376
Supervisor(s), interviews with, 202
Supramalleolar orthosis, UCBL, 390, 391f
Sural nerve, entrapment of, 377
Survival curve, 9, 10f
T
Talocalcaneal joint, 342
Talus, 341, 341f
fractures of
osteochondral lesions of
workplace-related, 355, 355t
TARGA-16based video-digitization system, 316
Tarsal bones, of midfoot fractures, workplace-
related, 360
Tarsal navicular stress fracture, 374
Tarsometatarsal (TMT) joint, 342
Tarsometatarsal (TMT) joint injuries
Technetium bone scanning
Tendinitis, 237238, 237f, 238f
ankle-related, diagnosis and treatment of, 370372
knee-related, treatment of, 305306
lower extremityrelated, 269
Tendinopathy, 238, 370
about elbow, 177
Tendon excursion, wrist and hand, 220221, 222f
Tennis elbow, 149
resistant, 152
Tennis toe, 381
Testing, defined, 398t
TFCC. See Triangular fibrocartilage complex
(TFCC)
The Medical Disability Advisor, 411
Thomas test, 290, 291f
Thoracic outlet syndrome, tests for, 65
Thoracic spine, biomechanics of, 4154
Thumb(s)
gamekeepers, 242, 242f
skiers, 242, 242f
Thumb basilar joint, osteoarthritis of, 245245f
Tibial pilon fractures, workplacerelated, 352
Tibialis posterior tendon insufficiency, workplace
adaptation of workers with, 390, 391f
Tibialis posterior tendon overuse problems,
Time-based observations, event-based
observations vs., in analysis of job
task demands, 203
Tinea pedis, 381
Tinels sign, 364, 375
Tinels test, 239
TMT joint injuries. See Tarsometatarsal (TMT)
joint injuries
Toe(s)
hammer, 379380
soccer, 381
tennis, 381
Toe blisters, safety footwear and, case study,
388, 388f
Toe fractures, workplace-related, 361362
Toenail(s)
fungal infections of, 382
ingrown, 381
problems related to, 381382
Tool counterbalancers, 259260
Tool torque buildup model, 260261, 260f
Tool weight control, in workplace adaptation
for shoulder disorders, 206
Torque reaction arms, 258, 259f
Torx head screws, 251f, 252, 252t
Total contact cast, 391, 391f
Total hip replacement, indications for, 299, 301
Touch-Test Sensory Evaluators, 231, 231f
Touch-Test Two-Point Diskcriminator,
231, 231f
Training, described, 89
Transversal tarsal joint, 342
Trendelenburg sign, 375
Trendelenburg test, 290, 290f
Triangular fibrocartilage complex (TFCC),
240f, 241, 241f
Trigger finger, 237238, 238f
Trochanteric bursitis, treatment of, 301
20002010 Bone and Joint Decade Task Force
on Neck Pain and Its Associated
Disorders, 25, 26
U
UCBL. See University of California
Biomechanical Laboratory (UCBL)
UCBL supramalleolar orthosis, 390, 391f
Ulceration(s), neuropathic, on plantar surface of
foot in diabetics, 391, 391f
Ulnar artery, superficial palmar branch of,
occlusion of, 213
Ulnar tunnel syndrome, 239
Ulnohumeral joint, articulation of,
163164, 163f
Ultrasonography, in low back pain evaluation,
121122
University of California Biomechanical
Laboratory (UCBL) supramalleolar
orthosis, 390, 391f
Index 427
University of Michigan Three-Dimensional
Static Strength Prediction Program, 204
Unnas paste boot bandage, 386, 387f
Upper Body Musculoskeletal Assessment, 228
Upper extremities, 145263. See also Shoulder(s);
specific sites, e.g., Hand(s)
impairments of, rating of, AMA guides in, 414
U.S. Bureau of Labor Statistics, 3, 4
U.S. Department of Labor
DOT of, 399, 400t
O*NET of, 234
U.S. Dictionary of Occupational Titles, Worker
Qualification Profiles of, 234
U.S. Marine Corps, 332
U.S. National Health survey, 88
U.S. Social Security Disability Insurance
System, 103
U.S. Supreme Court, 56
Utility, of FPE, 406
V
Validity
defined, 403t
of FPE, 402405, 403t
in aerobic capacity testing, 404405
legal constraints challenging, 400
sincerity of effort in, 402403
in work-related activities evaluation, 403404
types of, 403t
Valleix phenomenon, 375376
Valpar Corporation Work Samples (VCWS), 234
Valsalva maneuver, 64
Variance, 10
Varus stability, of elbow, 178
Vascular problems, of lower extremity,
VCWS. See Valpar Corporation Work Samples
(VCWS)
Venous disorders, foot and anklerelated,
workplace adaptation of workers
with, 392393
Verrucae vulgares, 381
Veterans Affairs Health Care System, exercise
laboratories of, 401
Vibration white finger disease, 213, 239-240
Video recordings, job-related, 201202
Video-digitization system, TARGA-16based, 316
Visual Analog Scale, 227, 232
Volar retinacular ganglia, 246
W
Walking
during ADLs, joint forces and, 283284
prolonged, jobs requiring, shoe inserts/insoles
for, 320
in workplace, 384
Wart(s), of foot, 381
Weight, as factor in internal joint forces for hip
and knee, 277279, 278f
Weinstein Enhanced Sensory Test (WEST), 231
Whiplash injury, 8283
Wilcoxon method, 9
Women, at workplace, footwear for, 388
Work ability, in disability evaluation, 411412
Work activities, biomechanical demands on foot
and ankle during, 384
Work equipment, measurements of,
as job task, 202
Work methods, 88
Work objects, placement of, 197t, 198t,
202t, 204
Work populations, accommodation for, process
of, 195, 195f
Work sampling, 201
Work standards, 88
Work stations
designing of, placement of work objects, 197t,
198t, 202t, 204
measurements of, as job task, 202
suppliers for, websites of, 144
Worker(s)
accommodation for, process of, 195, 195f
activities of, observations of, 200201
interviews with, 202
MSDs in. See also under specific disorders and
Musculoskeletal disorders (MSDs)
neck pain in, epidemiology of, review of,
2540. See also Neck pain, in workers,
epidemiology of
Worker capacity, 198200, 199t, 200f, 200t, 201f
Worker fitness and weight, in workplace
adaptation for shoulder disorders, 207
Worker Qualification Profiles, of U.S. Dictionary of
Occupational Titles, 234
Workers Compensation Board, 135
Workload, as factor in elbow and shoulder
disorders, 151152
Workplace
activities in, biomechanical demands on foot
and ankle during, 384
footwear at, 387388, 387f, 388f. See also
Shoe(s)
lower extremity disorders in, 309327.
See also Lower extremity disorders,
workplace-related
Workplace adaptation. See also Work stations
for foot and ankle disorders, 383393.
See also Foot and ankle disorders,
workplace adaptation of workers with
for low back pain, 135144. See also Low back
pain, workplace adaptation for
to MSDs, neck-related disorders, 8793
evaluation of, 87, 88t, 8990, 89t, 90f92f, 92
specification of, 8789
for shoulder disorders, 195208.
See also Shoulder disorders,
workplace adaptation for
Workplace injuries, foot and ankle, 351366.
See also Foot and ankle disorders,
workplace-related
Workplace layout, 88
Work-related activities
evaluation of, FPE validity in, 403404
FPE of, reliability of, 401402
Work-related performance tests, 399
World Health Organization, 97
Wrist. See also Wrist and hand
carpal joint of, force through, 223224, 223f
ganglia of, 246, 246f
osteoarthritis of, 244245, 244f
Wrist and hand, 209263
force through wrist carpal joint, 223224,
223f
motion, 219220
muscle and joint forces, 221223, 223f
posttraumatic injury, 224, 224f
skeletal and ligamentous anatomy/joint
constraint, 219, 220f, 221f
strength, 220
tendon excursion, 220221, 222f
edema, 228229, 229f
muscle performance testing, 229230, 230f
pain, 232
range of motion, 228
sensation, 230232, 231f, 232f
evaluation of, 227235. See also specific types,
e.g., Wrist and hand, clinical evaluation of
clinical assessment, 228232
functional assessment, 232234
multidimensional assessment, 227228
functional evaluation of, 232234
ADLs, 233
dexterity, 233234, 233f, 234f
information processing, 232233
physical capacity evaluation, 234
Wrist and hand disorders. See also specific
disorders, e.g., de Quervain disease
costs of, 213
disability burden associated with, 212213
early history of, 211
epidemiology of, 211218, 211f, 212f, 214t, 215t
frequency of, 211213, 212f
incidence of, 211213, 212f
hand-arm vibration syndrome, 213
hypothenar hammer syndrome, 213
individual factors in, 212f, 213214
occlusion of superficial palmar branch of ulnar
artery, 213
CRPS, 247
CTS, 238239
de Quervain disease, 237, 237f
fingers, 242
fractures, 242244, 243f
gamekeepers thumb, 242, 242f
ganglia, 246247, 246f
hand-arm vibration syndrome, 239240
lunotriquetral interval injury, 241
osteoarthritis, 244246, 244f, 245f
scapholunate interval injury, 240241, 240f
sprains, 240242, 240f242f
tendinitis, 237238, 237f, 238f
tendinopathies, 238
TFCC, 240f, 241, 241f
trigger finger, 237238, 238f
ulnar tunnel syndrome, 239
types of, 213
vibration white finger disease, 213
work-related factors in, 212f, 214216, 214t, 215t
Y
Yergasons test, 172
Index 428

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1600 John F. Kennedy Blvd.

Reassure the worker and provide adequate information about

Advise the worker to continue normal activity and work or

Because most workers with lower back pain manage to return

If a worker fails to return to work within 2-12 weeks (different

Upper cervical spine: occiput, atlas, axis;

Lower cervical spine: C2-C3 to C7;

Cervical-thoracic junction: C7 to the third thoracic vertebra

Clonus is elicited by the examiner rapidly dorsiflexing the

Lhermittes sign (a.k.a. the barbers chair phenomenon) is a

Babinskis sign is an abnormal reflex elicited by stroking the

Oppenheims sign is indicative of disease of the pyramidal

Hoffmans sign is a pathologic reflex elicited by flicking

An inverted brachioradialis reflex is elicited by tapping the

In a grip and release test, the patient should be able to rapidly

A scapulohumeral reflex is elicited by tapping the vertebral

A pectoralis reflex is an indication of hyperreflexia. The reflex

Job designers, such as engineers, facilities people, and setup

Safety and health personnel, such as doctors, nurses, industrial

Workers or work representatives;

Sales and technical representatives from suppliers;

Catalogs, brochures, and technical specifications;

Scientific papers, books, and magazines.

Two hands are usually better than one.

Force capability decreases when it is used more often.

Initial force capability is higher than sustained capability.

Pushing capability is higher than pulling capability.

Pushing should be done at waist level and pulling at thigh

This concomitant injury may be missed if one is not

References 32, 65, 93-95, 113, 142.

The procedure theoretically functions by provision of an ante-

Formal job title (in company documentation)

Work objectives (one or more reasons that the job exists)

Tools and equipment (ID, size, weight)

Materials and parts (ID, size, weight)

Methods (step-by-step description in necessary detail of what

Work station (sketched or described with key dimensions)

Environment (location and conditions of job)

All exposed and control subjects are female.

Significant difference from control.

Adjusted for age, sex, and plant.

Cohort study with a 31-month follow-up.

Controlled for age, gender, and years on job.

Significantly different from control group.

Controlled for age and gender.

cos cos sin

Chapter 6e Power hand tools 253

Score A (trunk, neck, and legs) = 7 (on a scale of 1 to 12)

= 4 + 2 (load/force: > 10 kg for the 24-lb tool) + 1 (load/

Score B (upper arms, lower arms, and wrist) = 1 (on a scale of

Score C (combination of scores A and B from Table C) = 7 (on

REBA score = 9 (on a scale of 1 to 15)

= 7 (score C) + 1 (activity score: static load of carrying tool)

REBA action level = 3 (on a scale of 0 to 4)

High risk level requiring action necessary soon.

Frequent walking on various surfaces;

Ascending and descending staircases three to five times a day

Climbing portable and fixed ladders four to five times per

Occasionally climbing on various machines and structures to

Static standing on a concrete floor for up to an hour at a time;

Occasionally crouching, once or twice a day, to work on low

The keystone effect of the talus, cuboid, and middle cuneiform