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This self-directed learning module highlights new advances in this topic area. It is part of the chapter on industrial rehabilitation medicine in the Self-Directed Medical Knowledge Program for practitioners and trainees in physical medicine and rehabilitation. This article covers ergonomic assessment of upper limb and low back injury, medical diagnostics for upper extremity cumulative trauma disorder (UE-CTD) and low back pain, and an evaluation of delayed recovery following work injury. Advances that are covered in this article involve factors contributing to UE-CTD, lumbar spine-imaging techniques, and the high-risk variables that contribute to prolonged disability.

Pain and stiffness of the injured region after prolonged periods of inactivity is commonly encountered following soft tissue injuries in sports. The injury in most of these instances is due to stress failure although occasionally an acute injury with a protracted course in recovery may develop similar symptoms. The most common of these condition are the enthesopathies, that include tendonitis and fasciitis, sprains and strains, bursitis, tenovaginitis and the fibrositis syndrome.

1. Elements critical to a successful medical management program include cumulative trauma disorder (CTD) surveillance, conditioning and rehabilitation programs, and familiarity with OSHA recordkeeping requirements, in addition to recognition, evaluation, and treatment. 2. Occupational health care providers (HCPs) can identify high risk departments, production lines, or jobs through the passive and/or active surveillance systems. 3. The HCP should perform a CTD evaluation of employees assigned to jobs with known ergonomic hazards or areas found to have CTD problems by the surveillance system. These evaluations should consist of a medical and occupational history, and a physical examination of the upper extremities. 4. The treatment algorithm emphasizes that a) symptomatic employees need follow up to determine the effectiveness of the prescribed treatments, b) employees with severe symptoms, positive physical findings, or disorders resistant to treatment need to be referred to a physician for further evaluation, and c) conservative therapy deserves an adequate trial before surgical intervention is contemplated.

Repetitive strain injuries include a group of disorders that most commonly develop in workers using excessive and repetitious motions of the neck and upper extremity. A careful occupational history, physical examination and specific diagnostic maneuvers can help distinguish these musculoskeletal injuries from rheumatologic diseases, psychologic disorders, acute joint or tendon inflammation from other causes and single-event traumatic sprains and strains. Repetitive strain injury may be manifested by cervical syndrome, tension neck syndrome, thoracic outlet syndrome and frozen shoulder syndrome. Common injuries involving the elbow, wrist and hand include epicondylitis, carpal tunnel syndrome and ulnar nerve entrapment. Conservative treatment consisting of rest, application of ice or heat and anti-inflammatory drugs is usually effective, but the injury may take weeks or months to resolve. Modifications in the workplace can prevent many of these injuries and may be required to prevent reinjury after the patient returns to work.

The exact pathomechanics of problems in the wrists of gymnasts are yet to be defined. This article discusses injuries and overload phenomena in the wrist and skin problems, fractures, and sprains of the hand, including mallet finger.

Overuse injuries are the result of repetitive microtrauma to the musculotendinous unit. Treatment protocols are based on the stage of the inflammatory process that is active at the time of diagnosis. Control of the inflammatory response with rest, elevation, and ice is the treatment objective during the inflammatory stage. Prevention of further injury is the primary treatment goal throughout the proliferative phase. Once the inflammatory process has reached the maturation stage, rehabilitation can begin with flexibility exercises, isometric contractions, and a slow return to strength training. Surgical decompression is frequently necessary if chronic inflammation causes fibrosis of the fibro-osseous tendon sheaths. Anomalous muscle bellies and tendinous interconnections can be contributing factors to overuse syndromes. Properly structured training programs and rehabilitation regimes can prevent tendinitis and overuse syndromes.

Overuse injuries are caused by intrinsic and extrinsic factors. Exercise exposes even the most subtle anatomic imperfections and extrinsic influences. Overuse that is not musculoskeletal in nature and new information pertaining to the role of bursae are discussed. Treatment philosophy is approached with an emphasis on history taking.

Shoulder problems in the overhead and throwing athlete can result in rotator cuff tendinitis. Biomechanically, there is a delicate balance between mobility and stability of the shoulder complex. Repetitive overhead stressful motion can lead to overuse tendinitis, subtle instability, labral changes, and eventual fiber failure of the rotator cuff. Secondary impingement symptoms are commonly present. An accurate diagnosis along with an early and aggressive rehabilitation program is essential in the treatment of these athletes.

A recent surge of interest for tennis has given rise to an increased incidence of injuries to the N. suprascapularis. The early symptoms of this pathology are often missed, leading subsequently to a chronic condition, including an irreversible trauma to the nerve. Nevertheless, through the study of three groups of professional tournament players, we were able to show that the neurological injury is reversible if the diagnosis is established early on and if the hurting movement is avoided until full recovery. A backhand stroke done with both arms seems to have a protective effect against this pathology.

Nineteen Ss who experienced chronic, occupational pain of the upper limbs and who had previously completed a programme of either individual or group cognitive-behaviour therapy were followed up 2 yr later. Significant improvements on measures of depression, anxiety, coping strategies and interference in daily living were found following treatment. Such improvements were not evident for the waiting list control Ss and no difference was found between group vs individual applications of therapy. A 2 yr follow-up, significant improvements from pre-treatment levels were evident for depression, coping strategies, significant other report of disability, self monitored pain and distress caused by pain. While there was generally little evidence of relapse, a significant decline from post-treatment levels was found for the individual therapy condition compared to the group therapy condition on measures of self monitored pain and interference caused by pain. Since post-treatment levels tended to be somewhat superior for the individual therapy condition, the overall finding at 2 yr follow-up was of minimal difference in outcome for group vs individual forms of cognitive-behaviour therapy. Despite improvements from pre-treatment levels, the vast majority of Ss still reported significant and distressing levels of pain at 2 yr follow-up.

Repetition strain injury (RSI), a non-specific and controversial constellation of work-related hand, arm and neck symptoms, became epidemic in Australian industry in the early 1980s. Fifty-two women who worked in a telecommunications organisation and a chicken processing factory and had been diagnosed as having RSI were interviewed about their perceptions and experiences of the illness. Their accounts of the search for caring and treatment, including their encounter with health and medical practitioners, suggest that the need to be believed and to establish their integrity dominated their 'pilgrimage'. The failure of the dominant explanations of RSI to accommodate the psychosocial and political dimensions of the illness thwarted this quest and, it is argued, contributed to its chronicity.

Among the 4,020 athletes (males 73%, females 27%) treated at the Department of Sports Medicine of the Deaconess Institute, Oulu, Finland in the period 1986-1989 there were 273 athletes with 330 of instances Achilles tendon overuse. Peritendinitis, tendinitis, partial rupture, retrocalcanear bursitis and insertiotendinitis were the most common diagnoses. Acute and subacute ailments were usually treated successfully by conservative means. 45.5% of the overuse injuries became chronic, failed to respond to conservative treatment and were treated surgically. The results were excellent or good in 86% of those operated on for chronic peritendinitis. The overall results were good in 69.3% of the patients.

Tendinitis and overuse syndromes plague athletes and performing artists. Although rarely career ending, both may impair performance for significant periods of time. This article emphasizes the distinction between these two entities and discusses proper diagnosis and treatment.

Musicians with overuse syndrome most commonly present with pain, inflammation, and soreness. The patient history and physical examination are the best diagnostic tools. Treatment may involve rest, splinting, and drug intervention. After the pain has subsided, progressive exercises may be appropriate. Prognosis is best with early detection and treatment.

This article discusses the importance of the elbow in both sports and performing arts. Functional, painless motion of the elbow is essential to achieve this end because although most objects of play are controlled by the hand, freedom of movement at the elbow allows one to place the hand in space. Anatomy and biomechanics of the wrist as well as common sports-related injuries are highlighted. In addition, wrist disorders affecting musicians are reviewed.

Hand symptoms in musicians reflect a complex, multifactorial etiology. A multidisciplinary approach is required for proper evaluation and treatment. Good results can be achieved in most patients with localized inflammatory and overuse disorders or nerve compression syndromes. Motor control disorders and chronic pain syndromes are associated with poorer results. Early diagnosis appears to improve outcome.

Vascular problems of the proximal upper extremity present with symptoms and signs of venous and arterial occlusion. They are rare, and sports medicine literature contains only case reports. Blunt trauma and activity requiring repetitive, overhead use of the arm are the usual mechanisms of injury. In athlete who perform repetitive upper-extremity activity, symptoms of easy fatigability of poorly localized pain and paresthesias should alert the treating physician to vascular occlusive disease. Published information suggests a good return-to-sport prognosis, but, because of the small number of cases, this information may be misleading.

Fourteen of 80 interpreters (18%) for deaf students at a national center on deafness sought medical care for painful conditions of the upper extremity; 11 others (14%) had less severe or transient symptoms. The conditions were brought on by repetitive use and were relieved by rest. All represented overuse syndromes. Tendinitis, fasciitis, synovitis, and nerve entrapment were encountered most often. Conservative treatment (eg, physical therapy, splinting, medications) was of little or no value. Only rest relieved symptoms. Surgery was rarely indicated. The most reasonable approach to treatment would, therefore, seem to be prevention. Suggested methods for avoidance of pain include limiting the duration of interpreting sessions, technique modification, and resistance exercises to increase endurance.

Six athletes, all engaged in running activities at the time of injury, presented with tenderness over the medial malleolus and ankle effusion. Three patients had a fracture line which could be seen on radiographs. These patients were treated by open reduction and internal fixation using two 4.0 cancellous screws. The other three patients had normal radiographs but bone scans showed increased uptake over the medial malleolus. These patients were treated with cast and immobilization. We believe that each of these patients suffered a stress fracture of the medial malleolus. We suggest that the possibility of a stress fracture be considered in the differential diagnosis of patients who present with 1) chronic or subacute pain over the medial malleolus and ankle effusion, and 2) a history of running activity at the time of injury or running activities aggravating the pain. Bone scans appear to be more sensitive than radiographs in detecting a stress fracture of the medial malleolus. We propose that athletes with radiographic signs of a medial malleolar fracture who desire early return to full participation should be treated by open reduction and internal fixation. For these patients, early motion can be initiated. Other athletes whose fracture cannot be detected on radiographs but whose malleolus shows increased uptake in the area on bone scans can be treated nonsurgically with immobilization and then progressive increase in activity. All of our patients returned to full activity between 6 and 8 weeks after treatment was initiated.

Fifty-four femoral neck stress fractures were studied prospectively to evaluate treatment methods. Fifty-four fractures in 49 patients were identified in a 4 year prospective study that included 1,049 stress fractures of all types. From our evaluation of treatment methods, a modification of existing classification systems was developed based on radiographic findings and treatment. Differences from earlier studies were noted in racial diversity, in nonprogression of tension-side fractures, and in return to function.

Racquet sports involve sharp, side-to-side movements and impose significant valgus and rotatory stresses on the knee. Most knee injuries are indirect as a result of these acute stresses and overuse. Some of the more common racquet sport injuries include tennis leg, jumper's knee, patello-femoral pain, meniscal injuries, bursitis, and tendinitis.

Multiple biologic and mechanical factors are involved in creating a stress injury to bone. The most common factor found to modulate this injury in the healthy individual has been the application of cyclic stress. The cessation of stress will allow repair to dominate over resorption. If bony integrity has not yet been lost, immobilization or fixation is not necessarily appropriate. By modulating the application of stress in a judicial manner, the injury is preventable.

Our knowledge of the etiology of shin splints is incomplete. Biomechanical abnormalities are likely to be major factors in predisposing certain persons to such injury. Also, training errors are major etiologic factors. Because shin splints result from mechanical overload of various elements of the musculoskeletal system of the leg that exceed their adaptive remodeling capacity, rest and recovery should be emphasized as an important aspect of sports training. Accurate and prompt diagnosis reduces the severity and duration of the injury. Management should consist of measures to reduce inflammation and pain and to identify possible biomechanical factors that may be correctable by strengthening and flexibility exercises or by the use of an orthotic device.

The traction apophysitises are one of the frequently encountered overuse injuries to children. Although known for many years and classed as osteochondroses, the traumatic origin of these disorders--from repetitive microtrauma--is now receiving wider acceptance. Discussion of the assessment, treatment, and prevention of these disorders is included.

The majority of adolescent tennis players will have their playing temporarily interrupted by an injury, with lower extremity problems predominating. Although upper extremity injuries occur less frequently, they tend to be more troublesome. Injuries discussed in this article include "King Kong arm," slipped capital humeral epiphysis, "Osgood-Schlatter disease" of the shoulder, tennis elbow, stress synovitis and elbow flexion contracture, and friction burns and collagen stress fractures of the rotator cuff.

This study presents eight patients with stress fracture of the anterolateral cortex of the midshaft of the tibia. All of the patients, ranging in age from 14 to 23 years, were competitive basketball players who experienced pain while running or jumping for an average of 4.4 months before the diagnosis was made. Eight patients were treated with rest and/or pulsing electromagnetic field therapy. Although one of the patients required bone grafting procedure, all eight of these patients showed complete healing and were able to return to full activity after an average of 8.7 months of treatment. They have remained asymptomatic for an average of 14.7 months. The overall time from initial symptoms to return to competition averaged 12.5 months in this group of athletes. The results presented in this paper suggest that rest and pulsing electromagnetic field therapy may result in healing in some patients with delayed union stress fractures of the anterolateral cortex of the midshaft of the tibia. Although this injury is associated with a prolonged healing period, seven of eight patients with adequate followup in our study were able to return to competition without complications following treatment. One patient was asymptomatic for 33 months before experiencing a reinjury. In conclusion, we feel that diagnosis of stress fracture should be primary consideration in basketball players presenting with a prolonged history of pain on the anterolateral aspect of the midthird of the tibia. Once the diagnosis is made we recommend initial treatment consist of rest and external electrical stimulation for a minimum time of 3 to 6 months prior to considering surgical intervention.

Overuse injuries are now well known to sports enthusiasts at any age or level of competition. The seeming explosion of overuse stress fractures of lower extremity bones in high-profile professional basketball players has brought about widespread media attention and a better understanding of the phenomenon of "overuse syndrome" by the public. However, the spectrum of overuse injuries in the child or adolescent athlete has only recently been recognized. These injuries can range from the permanent disability of osteochondritis dissecans of the elbow to the completely nonspecific "growing pains" of active youngsters.

An understanding of the cellular response to injury helps to explain overuse trauma. Tendons, bursae, cartilage, bone and nerves all can break down owing to the repetitive forces from sporting activities. A precise diagnosis and thoughtful use of medication and modalities in a complete rehabilitation program help to minimize disability.

Chronic inflammation and degenerative tendonitis of the supraspinatus muscle is an important cause of intrinsic shoulder pain. Injury to this muscle is usually caused, not by a single event, but by slight to moderate trauma repeatedly to the same anatomic area. The term repetition strain injury is used to describe this form of microtrauma. Repetition strain injury of the supraspinatus muscle is not an isolated event, but rather a form of microtrauma that affects the entire shoulder girdle. This functional unit must be evaluated and considered in the treatment plan. The authors discuss the diagnosis of this pain syndrome, which is based on the patient's work history, motion and strength testing, and palpation for trigger points. They also provide instruction in treatment involving manipulation with functional and counterstrain techniques combined with home exercise and modification of work posture.

360 observations were made on 120 cases of soft tissue injury divided into groups. 1. Among the 100 patients in the acupuncture treatment group, 300 observations were made; among the 20 controls there were 60 observations. The effective rate in the acupuncture treatment group was 85.00%; in the control group it was 41.67%, a very significant difference (P less than 0.01). 2. Relationship between therapeutic course and effect. The effective rate for the first course was 74.00%; it was 90.50% when more than two courses were given, a very significant difference (P less than 0.01) indicating the marked effect of acupuncture treatment. 3. Based on the therapeutic theory of TCM syndrome differentiation and reinforcement method in the asthenia state, and reducing method in asthenia state, different manipulations were used for asthenia-heat and asthenia-cold types with good clinical results. There was no significant difference (P greater than 0.05) between the effective rate in these two types, pointing up the significance of the TCM syndrome differentiation theory in clinical acupuncture. 4. There was very significant difference (P less than 0.01) in the degree of pressed pain on the patient's tender spot before and after acupuncture treatment, also (P less than 0.01 and P less than 0.001 respectively) in the EMG amplitude on the affected side of the lumbar area before and after acupuncture treatment during light and heavy force in extension action of back muscles. Acupuncture treatment on soft tissue disease based on TCM syndrome differentiation theory is thus shown to be effective.

Back ache in athletes is exceedingly common. Fortunately, most of these pain syndromes are self-limiting. A precise analysis of the patient will allow an accurate diagnosis, which leads to an understanding of the natural history of that particular problem. Surgical intervention is very rarely necessary and reserved strictly for those problems that are completely recalcitrant to nonsurgical measures.

Overuse injuries are common in recreational and competitive sports as well as in day-to-day activities. The musculotendinous unit comprises the tissue most frequently involved: structural damage to the tendon occurs from repetitive strain and loading, from either endurance or skill activities that require technique and power. The potential for injury is enhanced by a great variety of predisposing intrinsic or extrinsic factors. Tendinous tissue will become fatigued as its basal reparative ability is overwhelmed by repetitive dysfunctional and microtraumatic processes. Tendinitis is the earliest recognisable manifestation of overuse injury: as damage progresses, partial tears and complete ruptures may ensue. The diagnosis of overuse injury rests with identification not only of the affected tendinous unit, but also of the underlying predisposing condition or conditions. Treatment can then proceed with elimination or correction, if possible, of these conditions, together with control of inflammation and programmes of modalities designed to restore the structural and functional integrity of the tendon. Knowledge of overuse problems has grown exponentially in the past 3 decades, as evidenced by the outpouring of scientific and medical literature. Sophisticated analytical techniques, supplementing a sound history and physical examination, have greatly facilitated the diagnosis of overuse problems and allowed the application of scientific therapeutic principles. As the number of participants in recreational activities continues to grow, the application of these techniques in ever more innovative ways holds the greatest promise for the prevention of overuse tendon injuries.

Overuse syndrome, a condition of pain and loss of function in muscle groups and ligaments through excessive use, is common in musicians. In this series, the less serious cases of the disorder have been successfully treated by a modification of physical activity while allowing the musician to continue to play. The more serious cases were treated by a radical rest programme, first described last century, usually up to 12 months, until the patient is pain free and the muscles and ligaments are no longer tender. Performance is then very gradually resumed. The criterion for total success is a return to music performance free of pain with sustainable practice habits.

Improper techniques are often the cause of overuse syndromes. Unless the technique is corrected, the patient is doomed to recurrence. The same is true of improper posture, especially in the lower extremity and trunk areas. The pitcher or tennis player should have his or her style analyzed for proper form. The runner should have his or her muscular imbalances corrected by exercise and orthotic appliances. As with all other modalities used for treating painful conditions, proper evaluation of the etiology and the rectification of the cause is important. When athletes are underway in their sports seasons, it is often difficult to convince them to accept the ideal healing conditions needed to eliminate the problem. Management of the condition with any modality while maintaining an active lifestyle often brings about ethical scrutiny. However, it is the belief of the authors that noninvasive modalities do not provide the pain relief that would enable the athlete to tolerate activity beyond a significant injurious stress level. The modalities allow the athlete to regain the criteria for return, strength, and range of motion more successfully. Short-term goal setting is imperative to proper return. Several plateaus should be successfully completed before full return to activity is allowed. Tennis elbow, for example, may be allowed an initial period of 5 minutes on alternate days, gradually increasing to full activity every other day. Patients are often so anxious to return to activity that they overdo, leading to a decrease in function with a rapid return to the results of inflammation. The goals of successful rehabilitation of the overuse syndrome are pain-free range of motion, strength, and endurance. The use of cold, heat, electrotherapy, and exercise allow the athlete to reach his or her goal of returning to activity more quickly with a reduced risk of reinjury.