Occupational and Recreational Musculoskeletal Disorders 2017

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BOOK CHAPTER
Occupational and Recreational Musculoskeletal Disorders

Richard S. Panush
Kelley and Firestein's Textbook of Rheumatology, Chapter 35, 520-532
Key Points
Some occupational and recreational activities have been linked with musculoskeletal
syndromes or disorders that are manifested by neck pain; shoulder, elbow, hand, or wrist
pain or tendinitis; carpal tunnel syndrome; and hand-arm vibration syndrome. These
associations might be less clear than has been previously thought.
The intuitive concepts of so-called cumulative trauma disorders and repetitive strain
disorders have poor support in the literature. Causal relationships between most
occupations or activities and these “syndromes” have not been well established.
Some activities and mechanical stresses have been associated with osteoarthritis at certain
sites—for example, the hips of farmers, the knees of workers whose jobs involved frequent
bending of the knees, and the hands of workers who perform repetitive tasks with their
hands.
Certain rheumatic disorders have been related to environmental or occupational risks.
Putting a normal joint through its physiologic range of motion is not necessarily harmful
for an otherwise healthy individual. However, if the joint, motion, stress, or biomechanics
are not normal, there may be a risk of harm to the joint.
Most healthy persons comfortably engaging in reasonable recreational activities can do so

without evidence of lasting soft tissue or articular damage. Runners, who have been best
studied, exemplify this principle. Conversely, persons who exercise with pain, effusions,
underlying joint abnormalities or abnormal or unusual biomechanics, or as professional
or elite athletes may be at increased risk of joint injury.
Performing artists, vocalists, dancers, and musicians have a risk of soft tissue and joint
injury analogous to that of athletes.
“The diseases of persons incident to this craft arise from three causes: first
constant sitting, second the perpetual motion of the hand in the same manner, and
thirdly the attention and application of the mind. … Constant writing also
considerably fatigues the hand and whole arm….” —Ramazzini, 1713 1
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“When job demands … repeatedly exceed the biomechanical capacity of the
worker, the activities become trauma-inducing. Hence, traumatogens are
workplace sources of biomechanical strain that contribute to the onset of injuries
affecting the musculoskeletal system.” —National Institute for Occupational Safety and
Health, 1986 2
The possible associations of certain occupational and recreational activities with musculoskeletal disorders
are not as clear as had once been thought. Conventional wisdom was that “wear and tear” from at least some
activities led to reversible or irreversible damage to the musculoskeletal system. 2 3 4 5 Despite the
intuition that work or recreational activities might cause rheumatic and musculoskeletal syndromes, this
putative relationship is controversial and likely seriously flawed. Many of the available data have
confounding aspects, as will be discussed in this chapter.
Occupation-Related Musculoskeletal Disorders

Many presumptive work-related musculoskeletal disorders have been described and are presented in Table
35-1 (t0010) . 1 2 3 4 5 6 7 8 Although the appealing and suggestive names invite conclusions of causal
association, these have not been demonstrated. 1 2 3 4 5 6 7 8 Work-related musculoskeletal injuries
comprise at least 50% of nonfatal injury cases resulting in days away from work. 9 The cost of work-related
disability from musculoskeletal disorders has been equivalent to approximately 1% of the United States'
gross national product, making these entities of considerable societal interest. 10 Worldwide ergonomic
(occupational) disability from low back pain in 2010 was estimated to affect as much as 26% of the
population. 11 Industries with the highest rates of musculoskeletal disorders were meatpacking, knit-
underwear manufacturing, motor vehicle manufacturing, poultry processing, mail and message distribution,
health assessment and treatment, construction, butchery, food processing, machine operation, dental
hygiene and dentistry, data entry, hand grinding and polishing, carpentry, industrial truck and tractor
operation, nursing assistance, housecleaning, and, worldwide, agriculture. Associations between work-
related musculoskeletal syndromes and age, gender, fitness, and weight have been imprecise. 6 7 8 11
TABLE 35-1
Reported Occupation-Related Musculoskeletal Syndromes
Cherry pitter's thumb Gamekeeper's thumb
Staple gun carpal tunnel syndrome Espresso maker's wrist
Bricklayer's shoulder Espresso elbow
Carpenter's elbow Pizza maker's palsy
Janitor's elbow Poster presenter's thumb
Stitcher's wrist Rope maker's claw hand
Cotton twister's hand Telegraphist's cramp
Writer's cramp Waiter's shoulder
Bowler's thumb Ladder shins
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Jeweler's thumb Tobacco primer's wrist
Carpet layer's knee
From Mani L, Gerr F: Work-related upper extremity musculoskeletal disorders. Primary Care 27:845–864, 2000; and
Colombini D, Occhipinti E, Delleman N, et al: Exposure assessment of upper limb repetitive movements: a consensus
document developed by the Technical Committee on Musculoskeletal Disorders of International Ergonomics Association
endorsed by International Commission on Occupation Health. G Ital Med Lav Ergon 23:129–142, 2000.
A number of work-related regional musculoskeletal syndromes have been described. These syndromes
include disorders of the neck, shoulder, elbow, hand and wrist, lower back, and lower extremities 7 ( Table
35-2 (t0015) ); some of these syndromes are discussed in greater detail in other chapters. Neck
musculoskeletal disorders are associated with repetition, forceful exertion, and constrained or static
postures. Shoulder musculoskeletal disorders occur with work at or above shoulder height, lifting of heavy
loads, static postures, hand-arm vibration, and repetitive motion. For elbow epicondylitis, risk factors are
overexertion of finger and wrist extensors with the elbow in extension, as well as posture. Hand-wrist
tendinitis and work-related carpal tunnel syndrome were noted with repetitive work, forceful activities,
flexed wrists, and duration of continual effort. 1 7 Hand-arm vibration syndrome (Raynaud-like
phenomenon) 12 has been linked to the intensity and duration of exposure to vibration. Work-related lower
back disorders are associated with repetition, the weight of objects lifted, twisting, poor biomechanics of
lifting, and particularly agriculture. 11 13 Other risk factors for work-related musculoskeletal disorders
involving the back include awkward posture, high static muscle load, high-force exertion at the hands and
wrists, sudden applications of force, work with short cycle times, little task variety, frequent tight deadlines,
inadequate rest or recovery periods, high cognitive demands, little control over work, a cold work
environment, localized mechanical stresses to tissues, and poor spinal support. 1
TABLE 35-2
Selected Literature Describing Regional Occupation-Related Musculoskeletal Syndromes
Syndrome No. of Epidemiologic Studies Odds Ratio/Relative Risk
Neck pain 26 0.7-6.9
Shoulder tendinitis 22 0.9-13
Elbow tendinitis 14 0.7-5.5
Hand-wrist tendinitis 16 0.6-31.7
Carpal tunnel syndrome 22 1-34
Hand-arm vibration syndrome 8 0.5-41
Rehabilitation for these so-called occupational musculoskeletal disorders requires collaboration by workers,
employers, insurers, and health professionals. The process has been divided into phases of protection from
and resolution of symptoms, restoration of strength and dynamic stability, and return to work.
Not long ago, the prevailing view was that many musculoskeletal disorders were consistently and
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predictably work related. That understanding has been questioned and is now perceived more critically. 2
14 15 16 17 18 19 20 Much published information (see Table 35-2 (t0015) ) about occupational
musculoskeletal disorders is now considered flawed. The quality of this information was uneven and
perhaps poor in some instances. Definitions of musculoskeletal disorders were imprecise. Diagnoses, by
rheumatologic standards, were infrequent. Studies were usually not prospective, and selection and recall
biases were present. Inferential observations were made, and investigators had difficulty quantifying
activities and defining health effects. Outcome measures varied. The quality of reported observations was
uneven. Psychologic influences and secondary gain were often ignored. Claims, anecdotal, and survey data
were often used without validation of subjective complaints. Quantification of putative causative factors was
difficult. Indeed, a review of this literature concluded that none of the published studies satisfactorily
established a causal relationship between work and distinct medical entities. 17 In fact, certain experiences
argued powerfully against the notion of work-related musculoskeletal disorders. In Lithuania, for example,
where insurance was limited and disability was not a societal expectation or entitlement, “whiplash” from
auto accidents did not exist. 16 Similarly, when legislation for compensability was made more stringent in
Australia, an epidemic of whiplash and repetitive-strain injuries abated. 18 19 In the United States as well,
expressed symptoms correlated closely with the likelihood of obtaining compensation. 21 In other instances
it was found that ergonomic interventions had no effect on alleged work-related symptoms, and close
analysis of epidemics of work-related musculoskeletal disorders revealed serious inconsistencies. 14 A
Japanese study found no relationship between physical activity and musculoskeletal pain. 22 Interestingly,
another report described familial linkage to chronic musculoskeletal pain. 23 Thus the Industrial Injuries
Committee of the American Society for Surgery of the Hand and the American Society for Surgery of the
Hand, the Working Group of the British Orthopaedic Association, and the World Health Organization 2 14
17 18 have all stated that current data do not support a causal relationship between specific work activities
and the development of well-recognized disease entities; in addition, they have noted that these had become
socio-political problems and urged restraint in considering regulations regarding these so-called entities. 15
Hadler 2 14 also has written particularly forcefully that popular notions about work-related
musculoskeletal disorders have been based on inadequate science.
An appreciation of the importance of psychosocial factors influencing work disability has emerged. These
factors include lack of job control, fear of layoff, monotony, job dissatisfaction, unsatisfactory performance
appraisals, distress and unhappiness with co-workers or supervisors, repetitive tasks, duration of the work
day, poor quality of sleep, perceptions of air quality and ergonomics, poor coping abilities, divorce, low
income, less education, poor social support, presence of chronic disease, self-rated perception of poor air
quality, and poor office ergonomics. 2 14 15 16 17 18 19 20 21 24 25 This situation is reminiscent of the
story of silicone breast implants and their presumed association with rheumatic disease, where—as seems to
be the case for work-related musculoskeletal disorders—there was a coalescence of naïvely simplistic
assumptions, untested hypotheses, confusion between the repetition of hypotheses and their scientific
validation, media exaggeration, and public advocacy intertwined with politics and governmental regulatory
agencies, confounding compensatory rewards, litigation, and inadequate science. All these elements
perverted the silicone breast implant story 26 and may have confused the interpretation of evidence-based
work-related musculoskeletal disorders as well. More good quality, standardized investigation is necessary
to learn about work-related musculoskeletal disorders and to clearly identify the circumstances in which
they occur. Work-related musculoskeletal disorders exist, but they are less pervasive and less noxious than
originally thought.
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Occupation-Related Rheumatic Diseases

Associations between occupations and well-defined rheumatic disorders are clearer than those involving
musculoskeletal disorders. This discussion also recapitulates the simplistic perception that joints deteriorate
with use. However, this notion is neither necessarily logical nor correct.
Osteoarthritis
Is osteoarthritis (OA) caused, at least in part, by mechanical stress? OA is presented in Chapter 98 , Chapter 99
, Chapter 100 ; however, brief consideration of the role of certain occupational and recreational activities is
within the scope of this discussion. One analytic approach to determining a possible relationship between
activity and joint disease is to consider the epidemiologic evidence that degenerative arthritis may follow
repetitive trauma. Most discussions of the pathogenesis of OA include a role for “stress.” 27 28 29 30 31 32
33 34 35 36 37 38 39 40 Several studies have suggested an increased prevalence of OA of the elbows, knees,
and spine in miners 31 32 33 ; of the knees in floor layers and in other occupations requiring kneeling; of
the knees in shipyard workers and a variety of occupations involving knee bending; of the shoulders, elbows,
wrists, and metacarpophalangeal joints in pneumatic drill operators 34 ; of the intervertebral disks, distal
interphalangeal joints, elbows, and knees in dockworkers 32 ; of the hands in cotton workers, 35 diamond
cutters, 31 36 seamstresses, 36 and textile workers 14 37 ; of the knees and hips in farmers; and of the
spine in foundry workers 39 40 ( Table 35-3 (t0020) ). Population studies have noted increased hip OA in
farmers, firefighters, mill workers, dockworkers, female mail carriers, unskilled manual laborers, fishermen,
and miners and have reported increased knee OA in farmers, firefighters, construction workers, house and
hotel cleaners, craftspeople, laborers, and service workers. 39 40 Activities leading to an increased risk for
premature OA involved power gripping, carrying, lifting, increased physical loading, increased static
loading, kneeling, walking, squatting, and bending. 39 40 Recent studies and systematic reviews have
confirmed that heavy lifting and crawling and sometimes climbing were associated with knee and hip OA;
individual studies were variable, often small, and with interpretive limitations. 41 The effect of body mass
index (BMI) in work-related OA appeared to predispose toward the development of knee OA, with primarily
valgus malalignment. 42 43 A recent systematic review and meta-analysis concluded that data supported
risk of OA from activities involving heavy or manual work (average relative risk [RR], 1.45; range, 1.20 to
1.76), elite sports (RR, 1.72; range, 1.35 to 2.20), kneeling (RR, 1.30; range, 1.03 to 1.63), squatting (RR,
1.40; range, 1.21 to 1.61), lifting/carrying (RR, 1.58; range, 1.28 to 1.94), climbing stairs (RR, 1.29; range,
1.08 to 1.55), standing work (RR, 1.11; range, 0.81 to 1.51), and knee bending/straining (RR, 1.60; range, 1.15
to 2.21). 44 A common theme for occupational activities leading to knee OA was cumulative joint loading.
45 Bending was associated with magnetic resonance imaging abnormalities in cartilage of asymptomatic
persons, 46 as was physical activity, assessed by objective measures 47 48 49 ; injuries accelerated
progression of knee OA. 50
TABLE 35-3
Occupational Physical Activities and Possible Associations with Osteoarthritis
Occupation Involved Joints Risk of OA References * (hl0000336)
Miner Elbow, hip, knee, Increased Lawrence 32 (1955), Kellgren and Lawrence
spine 33 (1958), Felson et al. 39 40 (1997, 1998)
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Pneumatic driller Shoulder, elbow, Increased/none Jurmain (1977; cited in reference 47 ), Burke
wrist, MCP joint et al. 34 (1977)
Dockworker Intervertebral disk, Increased Lawrence 32 (1955); Anderson and Felson

DIP joint, elbow, hip, 38 (1988); Felson et al. 39 40 (1997, 1998)
knee
Cotton mill worker Hand Increased Lawrence 35 (1961)
Diamond worker Hand Increased Kellgren and Lawrence 31 (1957), Tempelaar

and Van Breeman 36 (1932)
Shipyard laborer Knee Increased Goldberg and Montgomery (1987; cited in

Felson et al., 39 40 1997, 1998)
Foundry worker Lumbar spine Increased Lawrence et al. (1966; cited in Felson et al.,
39 40 1997, 1998)
Seamstress Hand Increased Tempelaar and Van Breeman 36 (1932)
Textile worker Hand Increased Hadler et al. 37 (1978)
Manual laborer MCP joint, hip Increased Williams et al. (1987; cited in Felson et al., 39
40 1997, 1998); Anderson and Felson 38
(1988); Felson et al. 39 40 (1997, 1998);

McWilliams et al. 44 (2011)
Occupations Knee Increased Anderson and Felson 38 (1988); Felson et al.

requiring knee 39 40 (1997, 1998); McWilliams et al. 44
bending (2011)
Farmer Hip, knee Increased Anderson and Felson 38 (1988); Felson et al.
39 40 (1997, 1998)
Firefighter Hip, knee Increased Anderson and Felson 38 (1988); Felson et al.
39 40 (1997, 1998)
Millworker Hip Increased Anderson and Felson 38 (1988); Felson et al.

39 40 (1997, 1998)
Female mail carrier Hip Increased Anderson and Felson 38 (1988); Felson et al.
39 40 (1997, 1998)
Fisherman Hip Increased Anderson and Felson 38 (1988); Felson et al.

39 40 (1997, 1998)
Construction Knee Increased Anderson and Felson 38 (1988); Felson et al.

worker 39 40 (1997, 1998)
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House and hotel Knee Increased Anderson and Felson 38 (1988); Felson et al.
cleaner 39 40 (1997, 1998)
Craftperson Knee Increased Anderson and Felson 38 (1988); Felson et al.

39 40 (1997, 1998)
Service worker Knee Increased Anderson and Felson 38 (1988); Felson et al.
39 40 (1997, 1998)
Heavy lifter Hip, knee Increased Allen et al. (2010) 41
Crawling Hip, knee Increased Allen et al. (2010) 41
Kneeling Knee Increased McWilliams et al. 44 (2011)
Squatting Knee Increased McWilliams et al. 44 (2011)
Lifting/carrying Knee Increased McWilliams et al. 44 (2011)
Climbing stairs Knee Increased McWilliams et al. 44 (2011)
Standing work Knee Increased McWilliams et al. 44 (2011)
DIP, Distal interphalangeal; MCP, metacarpophalangeal; OA, osteoarthritis.
* As cited in Greer JM, Panush RS: Musculoskeletal problems of performing artists. Baillieres Clin
Rheumatol 8:103, 1994.
Studies of skeletons of several populations have suggested that age at onset, frequency, and location of
osteoarthritic changes were directly related to the nature and degree of physical activities. 51 However, not
all these studies adhered to contemporary standards, nor have they been confirmed. One report, for
example, failed to find an increased incidence of OA in pneumatic drill users and criticized inadequate
sample sizes, lack of statistical analyses, and omission of appropriate control populations in previous
reports. 33 The investigators further commented that earlier work was “frequently misinterpreted” and that
their studies suggested that “impact, without injury or preceding abnormality of either joint contour or
ligaments, is unlikely to produce osteoarthritis.” 34
Do epidemiologic studies of OA implicate physical or mechanical factors related to disease predisposition or

development? The first national Health and Nutrition Examination Survey of 1971 to 1975 (HANES I) and
the Framingham studies explored cross-sectional associations between radiographic OA of the knee and
possible risk factors. 38 39 40 41 42 43 52 Strong associations were noted between knee OA and obesity and
occupations involving the stress of knee bending, but not all habitual physical activities and leisure-time
physical activities (e.g., running, walking, team sports, racquet sports, and others) were linked with knee
OA. 27 28 29 53 54 55 (See Chapter 98 for a more detailed discussion of the pathogenesis of OA.)
Other Occupational Rheumatologic Disorders

Certain rheumatic diseases other than repetitive strain or cumulative trauma disorders have been reported
to be associated with occupational risks. Reports have been made of reflex sympathetic dystrophy after
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trauma; Raynaud's phenomenon with vibration or exposure to chemicals (particularly polyvinyl chloride);
autoimmune disease from teaching at a school, farming, occupations with exposure to animals and
pesticides, mining, use of a textile machine, and decorating operations 40 56 ; scleroderma from exposure to
chemicals, silica, and solvents and with use of vibrating tools 57 58 ; scleroderma-like syndromes from
exposure to rapeseed oil and l -tryptophan 58 59 ; systemic lupus erythematosus from exposure to the sun,
silica, mercury, pesticides, nail polish, paints, dye, canavanine, hydrazine, and solvents 60 61 and with
shiftwork and patient contact 62 ; lupus, scleroderma, and Paget's disease from exposure to pets 63 ;
granulomatous vasculitis from exposure to mercury and lead 64 ; primary systemic vasculitis from farming,
exposure to silica and solvents, and allergy 65 ; anti-synthetase syndrome from exposure to dust, gas, and
fumes 66 ; arthritis in patients with psoriasis from infections requiring antibiotics and in persons who have
performed heavy lifting 67 ; spondyloarthropathy from stressful events 68 ; gout (saturnine) and
hyperuricemia with lead intoxication 69 ; and rheumatoid arthritis (Caplan's syndrome) with silica
exposure, farming, mining, quarrying, electrical work, construction and engine operation, nursing, religious,
juridical, and other social science–related work, smoking, traffic and pollution, insecticides, and periodontal
disease 70 71 72 ( Table 35-4 (t0025) ).
TABLE 35-4
Other Reported Occupation-Related Rheumatic Diseases
Disease or Syndrome Occupation or Risk Factor
Reflex sympathetic dystrophy Trauma
Raynaud's phenomenon Vibration
Chemicals (polyvinyl chloride)
Autoimmune disease 40 56 Teaching at a school
Scleroderma 57 58 Chlorinated hydrocarbons
Organic solvents
Silica
Vasculitis 64 65 Mercury, lead, silica, solvents, allergy
Scleroderma-like syndromes 58 59 Rapeseed oil
l -Tryptophan
Anti-synthetase syndrome 66 Dust, gas, fume exposure
Systemic lupus erythematosus 61 62 63 Canavanine, hydrazine, mercury, pesticides, solvents, shift

work, patient contact
Lupus, scleroderma, and Paget's Pet ownership

disease 63
Rheumatoid arthritis (Caplan's Silica, insecticides, traffic, pollution, smoking, periodontal

syndrome) 70 71 disease
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Disease or Syndrome Occupation or Risk Factor
Arthritis in persons with psoriasis 67 Heavy lifting, infection requiring antibiotic treatment
Spondyloarthritis 68 Stressful events
Gout (saturnine) 69 Lead
Recreation- and Sports-Related Musculoskeletal Disorders

Do recreational or sports-related activities lead to musculoskeletal disorders? 72 73 74 75 76 77 78 79 80 81
82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 It has been suggested that the risk of joint degeneration

is increased by participation in sports that have high impact levels with torsional loading. 72 The presence
of prior joint injury, surgery, arthritis, joint instability and/or malalignment, neuromuscular disturbances,
and muscle weakness also predispose to higher risks of joint damage during sports participation. 72
Persons with sports injuries to the anterior cruciate and medial collateral ligaments (such as from downhill
skiing and football) frequently experienced the chondromalacia patellae and radiographic abnormalities of
OA (20% to 52%). 27 28 29 Retrospective studies found that OA was associated with varus deformity,
previous meniscectomy, and relative body weight. 73 74 99 Both partial and total meniscectomies have
been linked with degenerative changes. Early joint stabilization and direct meniscus repair surgery may
decrease the incidence of premature OA. Observations like these support the concept that abnormal
biomechanical forces, either congenital or secondary to joint injury, are important factors in the
development of exercise-related OA. 27 28 29 Other observations include certain physical characteristics of
the participant, biomechanical and biochemical factors, age, gender, hormonal influences, nutrition,
characteristics of the playing surface (when applicable), unique features of particular sports, and duration
and intensity of exercise participation, as has been reviewed extensively elsewhere. 27 28 29 It is
increasingly recognized that biomechanical factors have an important role in the pathogenesis of OA, as has
been presented.
Is regular participation in physical activity associated with degenerative arthritis? Several animal studies (of
tentative scientific relevance, but of interest) have suggested a possible relationship between exercise and
OA. For example, it has been stated that the husky breed of dog has increased hip and shoulder arthritis
associated with pulling sleds, that tigers and lions develop foreleg OA related to sprinting and running, and
that racehorses and workhorses develop OA in the forelegs and hind legs, respectively, consistent with their
physical stress patterns. 27 29 In rabbits with experimentally induced arthritis in one hind limb, progressive
OA did not develop when they exercised on treadmills, but OA did develop in sheep with normal health who
walked on concrete. Other studies found that OA did not develop in dogs (beagles) who ran 4 to 20 km a
day, 27 28 29 that lifelong physical activity (running) protected mice from OA, 100 that running 30 km in 3
weeks or 55 km in 6 weeks induced OA in rats, 101 and that running exacerbated induced OA in other rats.
102 Although these observations were not entirely consistent, they suggested that physical activities in some
circumstances might predispose to degenerative joint disease.
Human studies have provided pertinent observations 27 28 29 ( Table 35-5 (t0030) ). Wrestlers were reported
to have an increased incidence of OA of the lumbar spine, cervical spine, and knees; boxers, of the
carpometacarpal joints; parachutists, of knees, ankles, and spine, which was not confirmed; cyclists, of the
patella; cricketers, of the fingers; and basketball and volleyball players, of the knees.. 27 28 29 42 In
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addition, athletes involved in sports requiring repetitive overhead throwing such as baseball, tennis,
volleyball, and swimming were reported to have an increased incidence of early glenohumeral arthritis 77 ;
persons with meniscal and anterior cruciate ligament injuries incurred in youth-related sports were
reported to have an increased incidence of knee OA 78 ; soccer players were reported to have an increased
incidence of OA of the talar joint, ankle, cervical spine, knee, and hip 27 28 29 79 80 81 82 99 ; and OA of
the hips and knees of elite athletes from impact sports. 83 Studies of American football players have
suggested that they are susceptible to OA of the knees, particularly those who sustained knee injuries while
playing football. 30 Among football players (average age, 23 years) competing for a place on a professional
team, 90% had radiographic abnormalities of the foot or ankle, compared with 4% of an age-matched
control population; linemen had more changes than did ball carriers or linebackers, who in turn had more
changes than did flankers or defensive backs. All athletes who had played football for 9 years or longer had
abnormal radiographic findings. 27 28 29 30 78 Most of these studies were deficient in several respects:
criteria for OA (or “osteoarthrosis,” “degenerative joint disease,” or “abnormality”) were not always clear,
specified, or consistent; duration of follow-up was often not indicated or was inadequate to determine the
risk of musculoskeletal problems at a later age; intensity and duration of physical activity were variable and
difficult to quantify; selection bias toward persons exercising or participating versus those not exercising or
participating was not weighted; other possible risk factors and predispositions to musculoskeletal disorders
were rarely considered; studies were not always properly controlled, and examinations were not always
“blind”; little information regarding nonprofessional, recreational athletes was available; and little clinical
information about functional status was provided. 27 28 29 75 76 99
TABLE 35-5
Sports Participation and Alleged Associations with Osteoarthritis
Sport Site (Joint) Risk References * (hl0000620)
Ballet Talus Possibly to probably Ottani and Betti (1953), Coste et al.
increased depending on (1960), Brodelius (1961), Miller et al.
type, intensity, and (1975)
duration of participation
Ankle Washington (1978), Ende and
† (hl0000626)
Cervical spine Wickstrom (1982)
Hip
Knee Washington (1978)

Metatarsophalangeal
Baseball Elbow Adams (1965), Hansen (1982)
Shoulder Bennett (1941)
Boxing Hand Iselin (1960)

(carpometacarpal
joints)
Cricket Finger Vere Hodge (1971)
Cycling Finger Bagneres (1967)
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American Ankle Vincelette et al. (1972)

football Foot Rall et al. (1964)
Knee Richmond et al. 99 (2013)
Spine Ferguson et al. (1975), Albright et al.

(1976), Moretz et al. (1984)
Gymnastics Elbow Bozdech (1971)
Shoulder
Wrist
Hip Murray and Duncan (1971), Richmond

et al. 99 (2013)
Knee Richmond et al. 99 (2013)
Lacrosse Ankle Thomas (1971)

Knee
Martial arts Spine Rubens-Duval et al. (1960)
Parachuting Ankle Murray and Duncan (1971)

Knee
Spine Murray-Leslie et al. (1977)
Rugby Knee Slocum (1960)
Running (see Knee Small McDermott and Freyne (1983), Lane

Table 35-6 et al. (1986, 1987, 1998), Panush et al.
(t0035) ) (1986), Cheng et al. 92 (2000), Thelin
et al. 97 (2006), Chakravarty et al. 85
(2008), Hansen et al. 104 (2012),

Tveit et al. 83 (2012), Williams 91
(2013), Richmond et al. 99 (2013),

Miller et al. 98 (2014)
Hip Puranen et al. (1975), de Carvalho

and Langfeldt (1977), McDermott and
Freyne (1983), Lane et al. (1986,
1987, 1998), Panush et al. (1986),
Konradsen et al. (1990), Richmond
et al. 99 (2013)
Ankle Konradsen et al. (1990), Marti et al.

(1990)
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Soccer Ankle-foot Pellissier et al. (1952), Pellegrini et al.

(1964), Sortland et al. (1982)
Hip Klunder et al. (1980), Kuijt et al. 82

(2012). Tveit 83 (2012), Richmond
et al. 99 (2013)
Knee Pellissier et al. (1952), Solonen

(1966), Klunder et al. (1980), Thelin
et al. 97 (2006), Kuijt et al. 82 (2012),
Tveit 83 (2012),
Richmond et al. 99 (2013)
Talus Brodelius (1961), Solonen (1966)
Talofibular Burel et al. (1960)
Weightlifting Spine Aggrawal et al. (1965), Muenchow and

Albert (1969), Fitzgerald and
McLatchie (1980)
Wrestling Cervical spine Layani et al. (1960)

Elbow
Knee
* Cited in Panush RS, Lane NE: Exercise and the musculoskeletal system. Baillieres Clin Rheumatol 8:79,
1994; Panush RS: Physical activity, fitness, and osteoarthritis. In Bouchard C, Shephard RJ, Stephens T,
editors: Physical activity, fitness, and health. International Proceedings and Consensus Statement.
Champaign, Ill., 1994, Human Kinetics Publishers, pp 712–723; and Panush RS: Does exercise cause
arthritis? Long-term consequences of exercise on the musculoskeletal system. Rheum Dis Clin North Am
16:827, 1990.
† This risk level is true of all of the sports listed except running.
A number of studies have examined a possible relationship between running and OA. Uncontrolled
observations generally suggested that runners without underlying biomechanical problems of the lower
extremity joints did not develop arthritis at a different rate from a normal population of nonrunners.
However, persons who had underlying articular biomechanical abnormalities from a previously injured
joint (and perhaps elite athletes, particularly women) appeared to be at greater risk for the subsequent
development of OA. Early studies showed that groups of long-duration, high-mileage runners and
nonrunning control subjects had a comparable (and low) prevalence of OA and suggested that recreational
running need not inevitably lead to OA. 103 These observations have generally now been confirmed by the
original authors in long-term follow-up studies 85 and by other investigators 27 28 29 75 76 79 84 85 86 91
98 103 and in comprehensive reviews 88 99 104 ( Table 35-6 (t0035) ). Eight- and 9-year follow-up
observations were supportive; most of the original runners were still running, with a prevalence of OA that
was comparable with that of the control subjects. 76 Perhaps even more significant was the growing
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evidence that running and other aerobic exercise protected against the development of disability and early
mortality. 84 In another study, 85 former college varsity long-distance runners were compared with former
college swimmers; no association was found between moderate levels of running or number of years
running and the development of symptomatic OA. Other authors have concluded that running in and of
itself does not cause OA; rather, prior injuries and anatomic variances were directly responsible for some of
the changes. 27 28 29 103 Prospective studies have found that runners were not at risk for the development
of premature OA of the knees. 85 86 87 88 89 90 Runners had hip replacements less frequently than did
other persons (perhaps related to lower BMIs). 91 However, another recent study found that running 20
miles per week was associated with 2.4 hazard ratio for OA for men younger than 50 years. 92
TABLE 35-6
Studies of Running and Risk of Developing Osteoarthritis
References No. of Mean Mean No. Miles/Wk Comments

Runners Age of Years
(yr) Running
Minor et al. 319 NA NA NA OA noted more frequently in former runners

(1989; cited in [1] (with underlying anatomic “tilt”
[2] [3] ) abnormality— epiphysiolysis) than in
nonathletes
Puranen et al. 74 56 21 NA Champion distance runners had no more

(1975; cited in [1] hip OA than did nonrunners in their sixth
[2] [3] ) decade
De Carvalho and 32 NA NA NA Radiographic findings of runners' hips and

Langfeldt (1977; knees were similar to those of control
cited in [1] [2] [3] ) subjects
Marti et al. 94 20 35 13 48 OA occurred in runners with underlying

(1990) anatomic (biomechanical) abnormality
Sohn and 504 57 9-15 18-19 No association between moderate long-

Micheli 88 distance running and future development of
(1985) OA (of hip and knees)
Panush et al. 84 17 53 12 28 Comparable low prevalence of lower

(1986) extremity OA in runners and nonrunners
Lane et al. 75 41 58 9 5 h/wk No differences between runners and control

(1986) subjects in cartilage loss, crepitus, joint
stability, or symptoms
Lane et al. 498 59 12 27 No differences between groups in

(1987; cited in [1] conditions thought to predispose to OA and
[2] [3] ) musculoskeletal disability
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References No. of Mean Mean No. Miles/Wk Comments

Runners Age of Years
(yr) Running
Marti et al. 93 94 27 42 NA 61 More radiographic changes of hip OA in

(1989, 1990) former Swiss national team long-distance
runners than in bobsledders and control
subjects; few runners had clinical
symptoms of OA; no difference in ankle
joints
Konradsen et al. 30 58 40 12-24 No clinical or radiographic differences in

89 (1990) hips, knees, and ankles between runners
and nonrunners
Vingard et al. 95 114 50-80 NA NA Unvalidated questionnaire reported

(1995) threefold increase of hip arthrosis in former
athletes
Kujala et al. 90 342 NA NA NA More former athletes hospitalized with hip

(1994) OA than expected
Kujala et al. 79 28 60 32 NA Women soccer players and weightlifters,

(1995) nonrunners were at risk of premature OA
Panush et al. 16 63 22 22 8-yr follow-up of original observations made

103(1995) in 1986 still found no differences between
runners and nonrunners
Lane et al. 76 35 60 10-13 23-28 Running did not appear to influence the
(1998) development of radiographic OA (with
possible exception of spur formation in
women)
Cheng et al. 92 16,691 40% > Variable >20 miles/wk was associated (2000) with
(2000) subjects 50 2.4 hazard ratio for OA in men
Chakravarty 1/45 58 18 183.5 No increased OA in runners

et al. 85 (2008) h/wk
Hansen et al. NA NA NA NA Comprehensive literature review of in vitro,

104 (2012) animal, and human studies; “Low-and
moderate-volume runners appear to have
no more risk of developing OA than non-
runners. The existing literature is
inconclusive (for)… high-volume running…”
Williams 91 74,752 46 13 <1,8 – Fewer hip and knee replacements in

(2013) >5.4 MET runners
h/day
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MET, Metabolic equivalent of the task; NA, not available; OA, osteoarthritis.
Studies examining hip OA in former athletes 93 94 95 96 97 noted that former champion distance runners
had no more clinical or radiographic evidence of OA than did nonrunners. 89 However, another study
found more radiographic changes due to degenerative hip disease in former national team long-distance
runners than in bobsled competitors and control subjects. 105 In all the subjects studied, age and mileage
run in 1973 were strong predictors of radiographic evidence of hip OA; for runners, running pace in 1973
was the strongest predictor of subsequent radiographic evidence of hip OA in 1988. These authors
concluded that high-intensity, high-mileage running should not be dismissed as a risk factor for premature
OA of the hip. Other reports found that former top-level soccer players and weightlifters, but not runners,
were at risk for the development of knee OA, 79 96 but it was suggested elsewhere that former athletes
seemed to be disproportionately represented in hospital admissions for OA of hip, knee, or ankle. 96 A
questionnaire of former elite and track-and-field athletes noted they had increased hip OA. 95 Similarly,
radiographic OA of the hip and knee was reported in women who were formerly runners and tennis players.
96 Other investigators reported no correlation between OA and running but rather with other sports,
particularly soccer and tennis (where knee injuries were prevalent). 97 It was speculated that peak load per
unit distance (stride and short duration of ground contact) may explain the fewer injuries and reduced
prevalence of OA in running compared with certain other sports. 98
Cross-sectional studies on the effect of weight-bearing exercise on the development of OA of the hip, knee,
or ankle and foot must be interpreted with caution. The radiographic scoring methods used by each group of
investigators differ, and their reliability has not been adequately tested. This information is important when
the major end points in the studies are radiographic features of OA.
Performing Arts–Related Musculoskeletal Disorders

Musculoskeletal problems are common among performing artists. Performing artists—particularly
musicians and dancers—have unique medical and musculoskeletal problems that merit special
consideration. Injuries that might be trivial to others may be catastrophic to such artists. These injuries are
usually associated with overuse—the consequences of tissues stressed beyond anatomic or normal physical
limits. Understanding the technical requirements and biomechanics required in the performance of a craft
(art), as well as the lifestyle required to pursue a successful career in these fields, should help physicians
appreciate causative factors that lead to these injuries.
The following principles are important in treating such patients:
• Musculoskeletal problems constitute the bulk of health issues for these persons.
• Performing artists are usually wary of consulting with physicians and skeptical of their expertise.
• An appropriate evaluation should be carried out by someone knowledgeable about the technical and bio-
mechanical requirements of the patient's craft(s)/art(s). The evaluation should consider instrument(s),
instrument usage, travel with instruments, shoes, performance surface and setting, practice and
performance routines, repertoire, coaches and training/trainers, and lifestyle and psychological factors, as
appropriate.
• Evaluation should include attention to joint laxity and other physical features of the artist, as well as to
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their relationship to performance, considering the entities encountered as listed in Table 35-7 (t0040) . 105
106 107 108 109 The evaluation should assess muscle tension and fatigue. Patients should demonstrate
how they use an instrument while both the actively moving body parts and the relatively immobilized
parts are examined. 105 110 111
TABLE 35-7
Musculoskeletal and Rheumatic Disorders Associated with Overuse in Performing Artists
Instrument Affliction (Common Name) References * (hl0001051)
Piano, Myalgias Hochberg et al. (1983), Knishkowy and Lederman (1986)

keyboard
Tendinitis Hochberg et al. (1983), Caldron et al. (1986), Knishkowy
and Lederman (1986), Newmark and Hochberg (1987)
Synovitis Hochberg et al. (1983), Knishkowy and Lederman (1986)
Contractures Hochberg et al. (1983), Knishkowy and Lederman (1986)
Nerve entrapment
Median nerve (carpal Hochberg et al. (1983), Knishkowy and Lederman (1986)
tunnel–pronator syndrome)
Ulnar nerve Hochberg et al. (1983), Knishkowy and Lederman (1986)
Brachial plexus Hochberg et al. (1983), Knishkowy and Lederman (1986)
Posterior interosseous Hochberg et al. (1983), Charness et al. (1985)

branch of radial nerve
Thoracic outlet syndrome Hochberg et al. (1983), Knishkowy and Lederman (1986),
Lederman (1987)
Motor palsies Hochberg et al. (1983), Schott (1983), Caldron et al.

(1986), Knishkowy and Lederman (1986), Merriman et al.
(1986), Cohen et al. (1987), Jankovic and Shale (1989)
Osteoarthritis Bard et al. (1984)
Strings
Violin, viola Myalgias Fry (1986b), Hiner et al. (1987), Bryant (1989)
Tendinitis Fry (1986b), Hiner et al. (1987)
Epicondylitis Fry (1986b), Hiner et al. (1987)
Cervical spondylosis Fry (1986b), Hiner et al. (1987)
Rotator cuff tears Fry (1986b), Newmark and Hochberg (1987)
Thoracic outlet syndrome Roos (1986), Lederman (1986)
Temporomandibular joint Hirsch et al. (1982), Ward (1990), Kovera (1989)

syndrome
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Motor palsies Schott (1983), Knishkowy and Lederman (1986), Hiner

et al. (1987), Jankovic and Shale (1989)
Garrod's pads Bird (1987)
Nerve entrapment
Ulnar Knishkowy and Lederman (1986)
Interosseous Maffulli and Maffulli (1991)
Cello Myalgias Fry (1986b)
Tendinitis Caldron et al. (1986), Fry (1986b)
Epicondylitis Fry (1986b)
Low back pain Fry (1986b)
Nerve entrapment Caldron et al. (1986), Knishkowy and Lederman (1986)
Motor palsies Schott (1983)
Thoracic outlet syndrome Lederman (1987), Palmer et al. (1991)
Bass Low back pain Fry (1986b)
Myalgias Fry (1986b)
Tendinitis Caldron et al. (1986), Fry (1986b), Mandell et al. (1986)
Motor palsies Caldron et al. (1986)
Viola da Saphenous nerve Schwartz and Hodson (1980), Howard (1982)

gamba compression (gamba leg)
Harp Tendinitis Caldron et al. (1986)
Nerve entrapment Caldron et al. (1986)
Woodwinds
Clarinet and First web space muscle Fry (1986b), Newmark and Hochberg (1987)
oboe strain
Tendinitis Dawson (1986), Fry (1986b)
Motor palsies Jankovic and Shale (1989)
Flute Myalgias Fry (1986b)
Spine pain Fry (1986b)
Temporomandibular joint La France (1985)

syndrome
Tendinitis Patrone et al. (1988)
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Nerve entrapment
Digital Cynamon (1981)
Posterior interosseous Charness et al. (1985)
Thoracic outlet syndrome Lederman (1987)
Brass
Trumpet, Motor palsies Turner (1893), Dibbell (1977), Dibbell et al. (1979)
cornet
Orbicularis oris rupture Planas (1982, 1988), Planas and Kaye (1982)
(Satchmo's syndrome)
English horn de Quervain's tenosynovitis Studman and Milberg (1982)
French horn Motor palsies James and Cook (1983), Jankovic and Shale (1989)
Saxophone Thoracic outlet syndrome Lederman (1987)
Percussion Osteoarthritis Caldron et al. (1986)
Drums Tendinitis Fry (1986b), Caldron et al. (1986)
Myalgias Fry (1986b)
Nerve entrapment Makin and Brown (1985)
Cymbals Bicipital tenosynovitis Huddleston and Pratt (1983)

(cymbal player's shoulder)
Miscellaneous
Guitar, Tendinitis Newmark and Hochberg (1987)

strings
Synovitis Mortanroth (1978), Bird and Wright (1981)
Motor palsies Mladinich and De Witt (1974), Cohen et al. (1987),

Jankovic and Shale (1989)
Congas Pigmenturia Fenichel (1974), Furie and Penn (1974)
Spoons Tibial stress fracture (spoon O'Donoghue (1984)

player's tibia)
* As cited in Greer JM, Panush RS: Musculoskeletal problems of performing artists. Baillieres Clin
Rheumatol 8:103, 1994.
• Inquiry should be made about all prescription and nonprescription therapies, nutritional and exercise
practices, and non-mainstream (so-called “complementary and/or alternative”) treatments.
• The practitioner must have an understanding of and sympathy for the unique expectations of these
performers and expertise in assessing their medical problems and developing treatment plans.
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• Prevention should be emphasized—ensuring performance ability, promoting endurance and
conditioning, facilitating good posture, protecting joints, maintaining proper ergonomics, and
establishing appropriate exercise regimens. 110 111
• Therapeutic interventions will usually be conservative.
Instrumentalists
The frequency of musculoskeletal problems in musicians rivals the frequency of disability in athletes. Up to
82% of orchestral musicians have experienced medical problems (mainly musculoskeletal) related to their
occupation. Up to 76% of musicians have reported a musculoskeletal issue that is grave enough to influence
their ability to perform. 105 112 Woodwind players and female instrumentalists seem to be affected more
often compared with other types of other instrumentalists and male artists, respectively. Muscle-tendon
overuse or repetitive stress injuries, nerve entrapment problems, and focal dystonias are most common (see
Table 35-7 (t0040) ). 105 106
The causes of, mechanisms of, and therapies for these musculoskeletal problems are unclear. Overuse,
tendinitis, cumulative trauma disorder, repetitive motion disorder, occupational cervicobrachial disorder,
and regional pain syndrome have been considered critical risk factors in the development of joint laxity in
musicians. 112 Joint laxity declined with age and was associated with gender, starting earlier in men but
persisting in women through their mid 40s. The presence or absence of hypermobility at certain sites was
associated with musicians' reports of associated symptoms. Hypermobility in musicians might produce
advantages or disadvantages, depending on the site of the laxity and the instrument played. 113 Paganini,
with his long fingers and reported hyperextensibility, had a wider finger reach on the violin than his
contemporaries, but he may have had a predisposition to OA because of this. Of interest and seemingly
unexplained was the high frequency of symptoms among women (68% to 84%); perhaps this finding is
related to their higher incidence of hypermobility. 112 Stress also likely contributes to motor function
problems such as occupational cramps; dealing with this issue often requires the best efforts of a team of
physicians and therapists. 112 113 114 115
Vocal Artists
Musculoskeletal problems among singers have not been addressed extensively. The frequency of
musculoskeletal problems was the same in both instrumentalists and opera singers. However, singers had
more hip, knee, and foot joint complaints, perhaps reflecting the effects of prolonged standing. 114
Dancers
Dance has been viewed as a demanding art form. Classical ballet ranked first in activities generating
physical and mental stress, followed by professional football and professional hockey. The dancer and
athlete have much in common, but important differences in training and performance technique influence
the nature of their injuries. Other important sociocultural differences affect their care. Professional dancers
(as well as musicians and vocalists) traditionally have not been convinced that most physicians know how to
effectively approach the unique issues of dance and music. Injured dancers seeking care have often been
told that the treatment is to stop dancing. Others, seeking assistance with weight control, have been told to
gain weight. Dancers frequently underreport their injuries and seek care from nonmedical therapists.
The incidence of reported dance-related injuries ranged from 17% to 95%. 116 The majority of injuries
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involved the foot, ankle, and knee. It is difficult to generalize about dance injuries because “dance” and its
training, performance, and settings are so variable. Most injuries are from overuse and are rarely
catastrophic, regardless of the style or setting. 112 The distribution of injuries is strongly influenced by the
type and style of dance and the age and sex of the population. 113 117 A better understanding of the
technical and aesthetic requirements of a dance, as well as the biomechanics involved to perform these
requirements, is necessary to appreciate the type of injuries that can be sustained by dancers. For example,
ballet dancers in companies whose choreography emphasizes bravura technique with big jumps and
balances are more likely to experience Achilles tendinitis than are those in companies that do not have this
emphasis. Men are more likely to have back injuries because of the requisite jumping and lifting, whereas
women who dance en pointe are more prone to toe, foot, and ankle problems. Also in ballet, the most
important physical feature is proper turnout of the hip, which requires maximal external rotation of the
lower extremity that can result in hyperlordosis of the lumbar spine, valgus heel with forefoot pronation,
and external rotation of the knee. 116 118
Tendinitis of the flexor hallucis longus tendon, commonly known as dancer's tendinitis, may be confused
with posterior tibial tendinitis because of the location of pain at the posteromedial ankle. Other dancer- and
environment-related factors that increase the risk of dance-related injuries include nutritional status,
improper support from footwear and floors, and their rehearsal and performance schedules. 116 118 Most
dance shoes do not have a shock-absorbing sole, and some dances may be performed barefoot. 118
Traditionally constructed with paper, glue, and satin or canvas or leather, ballet pointe shoes tend to soften
once broken in, thus contributing to ankle injury. Intensive rehearsals before and during the opening
months of a performance season and pressures to return to work quickly after an injury must also be
considered in the care of dancers. 112 118 Touring companies may encounter nonflexible surfaces, including
concrete, predisposing to shin splints and stress fractures. Stress fractures may be associated with the
pressure to maintain a certain weight, resulting in amenorrhea, disordered eating, and low bone density.
Physicians caring for dancers, particularly ballet dancers at any level, must be aware of the aesthetic
pressures for extreme leanness and the potential health consequences. Unfortunately, the dance world is not
lacking in other serious medical problems including mental illness, drug abuse, and human
immunodeficiency virus infection. 112
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Occupational and Recreational Musculoskeletal Disorders- ClinicalKey https://www-clinicalkey-com.dbproxy.umfiasi.ro/#!/content/book/3-s2.0...

Occupational and Recreational Musculoskeletal Disorders

Certain rheumatic disorders have been related to environmental or occupational risks.

Most healthy persons comfortably engaging in reasonable recreational activities can do so

Occupation-Related Musculoskeletal Disorders

Cherry pitter's thumb Gamekeeper's thumb

Staple gun carpal tunnel syndrome Espresso maker's wrist

Bricklayer's shoulder Espresso elbow

Carpenter's elbow Pizza maker's palsy

Janitor's elbow Poster presenter's thumb

Stitcher's wrist Rope maker's claw hand

Cotton twister's hand Telegraphist's cramp

Writer's cramp Waiter's shoulder

Bowler's thumb Ladder shins

Jeweler's thumb Tobacco primer's wrist

Carpet layer's knee

Syndrome No. of Epidemiologic Studies Odds Ratio/Relative Risk

Neck pain 26 0.7-6.9

Shoulder tendinitis 22 0.9-13

Elbow tendinitis 14 0.7-5.5

Hand-wrist tendinitis 16 0.6-31.7

Carpal tunnel syndrome 22 1-34

Hand-arm vibration syndrome 8 0.5-41

Occupation-Related Rheumatic Diseases

Occupation Involved Joints Risk of OA References * (hl0000336)

Occupation Involved Joints Risk of OA References * (hl0000336)

Dockworker Intervertebral disk, Increased Lawrence 32 (1955); Anderson and Felson

Cotton mill worker Hand Increased Lawrence 35 (1961)

Diamond worker Hand Increased Kellgren and Lawrence 31 (1957), Tempelaar

Shipyard laborer Knee Increased Goldberg and Montgomery (1987; cited in

Seamstress Hand Increased Tempelaar and Van Breeman 36 (1932)

Textile worker Hand Increased Hadler et al. 37 (1978)

(1988); Felson et al. 39 40 (1997, 1998);

Occupations Knee Increased Anderson and Felson 38 (1988); Felson et al.

Millworker Hip Increased Anderson and Felson 38 (1988); Felson et al.

Fisherman Hip Increased Anderson and Felson 38 (1988); Felson et al.

Construction Knee Increased Anderson and Felson 38 (1988); Felson et al.

Occupation Involved Joints Risk of OA References * (hl0000336)

Craftperson Knee Increased Anderson and Felson 38 (1988); Felson et al.

Heavy lifter Hip, knee Increased Allen et al. (2010) 41

Crawling Hip, knee Increased Allen et al. (2010) 41

Kneeling Knee Increased McWilliams et al. 44 (2011)

Squatting Knee Increased McWilliams et al. 44 (2011)

Lifting/carrying Knee Increased McWilliams et al. 44 (2011)

Climbing stairs Knee Increased McWilliams et al. 44 (2011)

Standing work Knee Increased McWilliams et al. 44 (2011)

DIP, Distal interphalangeal; MCP, metacarpophalangeal; OA, osteoarthritis.

Do epidemiologic studies of OA implicate physical or mechanical factors related to disease predisposition or

Other Occupational Rheumatologic Disorders

Disease or Syndrome Occupation or Risk Factor

Reflex sympathetic dystrophy Trauma

Raynaud's phenomenon Vibration

Chemicals (polyvinyl chloride)

Autoimmune disease 40 56 Teaching at a school

Scleroderma 57 58 Chlorinated hydrocarbons

Vasculitis 64 65 Mercury, lead, silica, solvents, allergy

Scleroderma-like syndromes 58 59 Rapeseed oil

Anti-synthetase syndrome 66 Dust, gas, fume exposure

Systemic lupus erythematosus 61 62 63 Canavanine, hydrazine, mercury, pesticides, solvents, shift

Lupus, scleroderma, and Paget's Pet ownership

Rheumatoid arthritis (Caplan's Silica, insecticides, traffic, pollution, smoking, periodontal

Disease or Syndrome Occupation or Risk Factor

Spondyloarthritis 68 Stressful events

Gout (saturnine) 69 Lead