January 1996 Bulletin

Two views of musculoskeletal symptoms in the workplace - A question of causality

by Dean S. Louis, MD

Dean S. Louis, MD, is professor of surgery, section of orthopaedic surgery, and chief, Orthopaedic Hand Surgery, University of Michigan Hospitals, Ann Arbor, Mich. He also is president-elect, American Society for Surgery of the Hand.

Our understanding regarding musculoskeletal symptoms that occur in the workplace is continuing to evolve. One major confounding factor in this scenario is the lack of epidemiologic education by most orthopaedic surgeons. Arguments rage back and forth regarding causality of such symptoms.

The positions that have been advanced fit into one of three categories. The first of these is that work is not responsible for musculoskeletal symptoms, inasmuch as most people spend less than 15 percent of their lives from ages 18 to 65 actually engaged in vocational pursuits.1 The second position espoused is that musculoskeletal symptoms are multifactorial in origin and a joint product of vocational, recreational, and other pursuits combined. A further expansion of this view suggests that underlying disease or anomalies explain why one person develops symptoms and another doing the same job does not. The last position proposed is that work causes the symptom complex - no matter what it is, i.e., computer keyboards and the carpal tunnel syndrome.

Much of what we now experience is a result of imprecise use of language and undeniable dedicated self-interest. The terms "repetitive strain injury (RSI)" and "cumulative trauma disorders" imply and connote causality. A better term without bias would be musculoskeletal symptoms - barring any other specific diagnosis, i.e., carpal tunnel syndrome objectified by electrophysiologic tests. Thus, causation is not implied. The use of RSI in the lay press has been epidemic recently, probably due, in part, to vested interests in the publishing industry where computer-related symptoms may be considered compensable. The psychosocial epidemic called RSI occurred in Australia in the early 1980s. Patients who were told they had RSI believed it was a disease and considered their symptoms as something other than the transient aches and pains of daily life. When compensability was denied, the epidemic ceased. Presumably, the former claimants returned to their work and dealt with their symptoms as they had prior to being labeled with RSI.

The imprecise use of language expressed to a susceptible population was responsible for this problem. The term RSI is of historical interest, only its current usage is inappropriate.

Symptoms that change in time, intensity, and location usually defy discrete diagnosis and as such should not be labeled as "tendinitis" or "epicondylitis" or "tenosynovitis." These latter diagnoses all require histologic confirmation of an inflammatory reaction, and precise anatomical findings. If a patient is told that they have one of these conditions, then the tyranny of such words may cause them to overreact to a nonspecific symptom complex. Better to use terms such as "upper extremity pain" when a more specific diagnosis cannot be made.

Unfortunately, as the health care delivery system changes, the issue of work-relatedness will become more of a problem. The physician or group of physicians responsible for caring for a worker in the managed care environment may financially benefit by saying a problem is work-related, thus shifting the health care costs to the compensation system. Global attitudes regarding causation do patients (workers) a disservice. Each individual must be examined discreetly and specifically with a detailed medical history as well as a history of work and outside activities. The vast majority of workers with musculoskeletal symptoms want a diagnosis and/or treatment, but largely they want reassurance and an early return to work. On the other hand, the secondary agendas of the unmotivated and irresponsible will continue to challenge all of us.

The Academy's recent publication, Repetitive Motion Disorders of the Upper Extremity,2 deals with the breadth of these problems. Although we believe the title is inappropriate, the volume clearly points out the deficiencies in current epidemiologic reports and suggests that much more cooperation and understanding is needed between clinicians, surgeons, ergonomists, epidemiologists, and other occupational health care professionals. A skillful, compassionate clinician may be able to assist a worker through the multilayered maze once symptoms begin. We are potentially the most well-qualified to guide patients in this fashion. It does require a special commitment and nontraditional behavior on the part of the orthopaedist and hand surgeon. It is also entirely appropriate that we assist in changing an archaic workers compensation system that supplies rewards for lassitude and sloth rather than rewarding wellness.


1. Kasdan ML: Occupational cumulative trauma: A small fraction of life.
J Hand Surg 1994;19A:523.

2. Gordon S, Blair SJ, Fine LJ (eds): Repetitive Motion Disorders of the Upper Extremity. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995.

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