Cumulative trauma disorder

Cumulative trauma disorder (CTD) also known as chronic occupational repetitive strain injury (RSI), overuse injury or overuse syndrome, is a term for various injuries of the musculoskeletal and nervous systems that are caused by repetitive tasks, repetitive stressful movements, forceful exertions, vibrations, mechanical compression or sustained postures ¹. The term refers to a vast array of diagnoses that are often caused by occupational, recreational, and habitual activities ¹. Areas commonly involved are the hand, wrist, shoulder, and neck, resulting in disorders such as carpal tunnel syndrome and neck tension syndrome ². Cumulative trauma disorder is a common problem among adults, frequently the result of work-related activities ³. Individuals employed in clerical and computer work (jobs requiring light physical activity), are at high occupational risk for such disorders ⁴.

Common overuse injuries include the following:

• Acromioclavicular degeneration (eg, Acromioclavicular joint injury)
• Ankle degeneration
• Anterior cruciate laxity (eg, Anterior Cruciate Ligament Injury)
• Elbow degeneration (eg, Elbow and Forearm Overuse Injuries)
• Knee degeneration
• Neck pain
• Pronator teres syndrome
• Medial tibial stress syndrome (shin splints)
• Plantar fasciitis
• Stress fracture
• Suprascapular nerve compression
• Tibialis anterior tendinopathy
• Tibialis posterior tendinopathy
• Achilles tendinopathy

Certain parts of the body are more susceptible to strains during participation in certain sports. Examples include:

• Legs and ankles. Sports that feature quick starts and jumping, such as hurdling and basketball, can be particularly tough on the Achilles tendon in your ankle.
• Hands. Gripping sports, such as gymnastics or golf, can increase your risk of muscle strains in your hands.
• Elbows. Elbow strains are often caused by throwing sports and racquet sports.

If you suspect that you have an overuse injury, consult your doctor or physical therapist. He or she will likely ask you to take a break from the activity that caused the injury, but you may be able to perform alternative training as long as it does not stress the involved body part.

Be sure to tell your doctor or physical therapist if you’ve recently made changes in your workout technique, intensity, duration, frequency or types of exercises. Identifying the cause of your overuse injury will help you correct the problem and avoid repeating it.

Relative rest, particularly avoidance of the inciting activity, is a hallmark component of cumulative trauma disorder treatment ⁵. Using the involved area in nonpainful ways often helps to maintain range of motion (ROM). Total bed rest is virtually never advisable for these patients, and participation in a carefully planned physical therapy program is important.

Occupational therapists can help to identify workplace modifications. In cases of individuals with disabilities who develop overuse injuries as a result of the interface with adaptive equipment, occupational therapy may be of great benefit. Often, simple modifications in the manner in which the patient performs activities of daily living or modifications in the equipment itself confer relief.

Steroid injections are the most commonly used procedure in the treatment of overuse injuries, although controversy surrounding this therapy is still readily apparent. Tendons and ligaments can become structurally weakened by the use of steroids, predisposing them to rupture. The use of local anesthetics and steroids should be reserved for patients with significant pain who have the ability to change the underlying cause behind their injury. Repeatedly injecting patients who will inevitably return to the same routine that initially caused the injury is not advisable ⁶.

Surgical intervention is undertaken if conservative approaches fail and if the injury is amenable to surgery. In overuse injury, decompression of nerves and repair of lax or failed ligaments are the most common problems that lead to surgery. Surgeries that are performed solely to relieve pain in the absence of objective findings are notorious for suboptimal outcomes.

When you think the overuse injury has healed, ask your doctor or physical therapist to check that you’ve completely regained strength, motion, flexibility and balance before beginning the activity again. When you return to your activity, pay special attention to proper technique to avoid future injuries.

Cumulative trauma disorder causes

An overuse injury is any type of muscle, joint or nerve injury, such as tendinitis or a stress fracture, that’s caused by repetitive trauma. The most important factor leading to overuse injury is repetitive activity, although the specific type of force leads to different outcomes ⁷. A cumulative trauma disorder typically stems from:

• Training errors. Training errors can occur when you take on too much physical activity too quickly. Going too fast, exercising for too long or simply doing too much of one type of activity can strain your muscles and lead to an overuse injury.
• Technique errors. Improper technique also can take its toll on your body. If you use poor form as you do a set of strength training exercises, swing a golf club or throw a baseball, for example, you may overload certain muscles and cause an overuse injury.

Repetition is part of the definition of overuse injury. The concept is that overuse injury is associated with repeated challenge without sufficient recovery time.

Cycles and fundamental cycles are terms used to describe activities repeated at work. A cycle is a large-scale activity that is repeated throughout the day. A fundamental cycle is a small component of a cycle that may be repeated several times during the performance of a cycle. If a job has cycles that are repeated many times a day, the job is designated as repetitive. The tendency in industry to specialize labor for the sake of efficiency and better productivity has resulted in fewer different tasks per job. These tasks are repeated frequently, and this repetition is believed to be a contributing factor to the increase of overuse injury claims. Repetitiveness and force exerted are features of a task that increase the risk of sustaining an overuse injury.

However, there have been studies that dispute this theory, finding that cycle times and repetitive motions do not specifically lead to overuse injury in the upper extremity. Most articles in the literature, though, implicate repetitive motions as possible causes of injury,

Vibration, especially over long periods, has long been shown to be a factor in increasing the risk of many injuries (eg, lower back pain, intervertebral disk injury, wrist injury). One systematic review estimated that workers with hand-arm vibration exposure had a 4-5 times greater likelihood of developing neurologic and vascular diseases (ie, carpal tunnel syndrome, Raynaud phenomenon) ⁸.

The greater the forces involved in an activity, the greater the chance of developing an overuse injury ⁹.

Malpositioning limbs away from their neutral position increases the risk for overuse injury. Multiple articles in dental and surgical literature emphasize this point. Ergonomics is the field that focuses primarily on designing devices that lend themselves to good positioning. A massive increase has occurred in the amount of ergonomically designed work equipment, especially keyboards and mouses. The literature remains divided on their effectiveness in decreasing injuries.

A literature review found a moderate association between hand-arm symptoms and increasing duration of mouse use ¹⁰. There was a weaker association between neck-arm symptoms and mouse use. Nevertheless, prolonged computer and mouse use does not typically result in chronic neck and shoulder pain ¹¹. However, certain psychosocial factors may be predictive of chronic pain.

A literature review by Arnold et al ¹² concerning skeletally immature athletes with overuse physeal injuries found that risk factors for such trauma include periods of accelerated growth, body size, previous injury, chronologic age, and training volume.

A prospective study by Jayanthi et al ¹³ indicated that child athletes with a high degree of sports specialization are more likely to suffer injury, including overuse injury, than are less specialized athletes. The investigators, who looked at athletes aged 7-18 years, reported this outcome to be more likely in females. The study also found that those young athletes for whom the number of hours spent training each week exceeds their age are at greater risk for overuse injuries, as are those who spend more than twice as many hours per week in organized sports than in free play.

A study by De Bleecker et al ¹⁴ indicated that in athletes competing in sports that require repeated use of landing maneuvers, knee overuse injuries are more likely in those whose landing is characterized, at initial contact, by greater hip adduction and increased knee internal rotation, as well as by greater peak knee external rotation and reduced ankle dorsiflexion at peak vertical ground reaction force. Moreover, overuse injuries of the groin were found to correlate with greater range of motion in the pelvic and hip frontal and transversal planes.

Cumulative trauma disorder high-risk jobs

Any manual task that requires fast and repetitive movements or working in fixed or awkward postures for long periods of time can trigger cumulative trauma disorder. Anyone who works with their hands, such as hairdressers, musicians and mail workers, can experience cumulative trauma disorder.

Occupations at risk include:

• office work – such as typing and clerical duties
• process work – such as assembly line and packing
• piece work – such as sewing
• manual work – such as bricklaying and carpentry.

Risk factors in developing cumulative trauma disorder

Workplace design and work practices can contribute to cumulative trauma disorder. Risk factors can include:

• furniture, tools or equipment that don’t conform comfortably to the body
• benches or workstations that are too high, too low or too far from the body
• machinery that operates too quickly for user comfort, such as speedy conveyor belts that force the worker to move fast
• workspace design that requires repeated bending, stretching or twisting
• tight deadlines that prevent workers from taking sufficient breaks
• repetitive manual tasks.

Although an overuse injury can happen to anyone, you may be more prone to this type of injury if you have certain medical conditions. Overuse injuries are also more likely to occur as you get older — especially if you don’t recognize the impact aging can have on your body and modify your routine accordingly.

For these reasons, it’s a good idea to talk to your doctor before starting a new activity or ramping up your current routine. Your doctor may offer tips to help make physical activity safer for you. If you have a muscle weakness in your hip, for example, your doctor may show you exercises to address the problem and prevent knee pain.

Cumulative trauma disorder pathophysiology

The pathophysiology of overuse injuries is based on the idea that tissues adapt to the stresses placed on them over time. These stresses include shear, tension, compression, impingement, vibration, and contraction. Mechanical fatigue within tendons, ligaments, neural tissue, and other soft tissues results in characteristic changes depending on their individual properties. This fatigue is theorized to initially lead to adaptations of these tissues. As the tissues attempt to adapt to the demands placed on them, they can incur injury unless they have appropriate time to heal. For overuse injuries, the rate of injury simply exceeds the rate of adaptation and healing in the tissue. Evidence also suggests that chemical mediators are involved in the initiation and propagation of overuse injuries.

Nerve tissues are at particular risk for ischemic injuries. This ischemia leads to characteristic changes in the nerve itself. The timeline generally begins with subperineurial edema, followed by thickening of the perineurium, thickening of the internal and external epineurium, thinning of the peripheral myelin, and, eventually, axonal degeneration.

One hypothesis is that the development of muscular pain originates from the nearly continuous activation of low-threshold motor units that occurs in muscles performing continuous or slow, repetitive tasks, causing depletion of adenosine 5′-triphosphate (ATP) in those fibers. With insufficient ATP, sarcoplasmic reuptake of Ca++ could be reduced, resulting in high concentrations in the cytosol, allowing Ca++ –dependent activation of phospholipase, the generation of free radicals, and damage to the muscle fibers involved. This theory has a rational physiologic basis, but it remains to be proven. Multiple studies have shown that patients with more significant work-related, upper extremity disorders exhibit more muscular activity on electromyelography (EMG) findings; however, these studies are observational and not designed to exhibit causality.

Increasing data in in vitro and in vivo human and animal models show that there are tissue-level changes associated with repetitive stress. Prostaglandin E2 has been found to be present in high quantities in overuse tissues in rat and chicken models ¹⁵. This mediator has been suggested to influence cell proliferation, increase collagenase, and decrease collagen synthesis. Increasing loads on these tissues alters the amount of nitric oxide and prostaglandin E2. However, another hypothesis based on rat-model observations suggests that overuse may lead to an understimulation of tendon cells, rather than to overstimulation ¹⁶.

Alterations in the regulation of genes within tendons undergoing overuse have been shown in the rat model ¹⁷. These changes include upregulation of genes associated with cartilage, and down-regulation of genes associated with tendon. This suggests that overuse may cause a morphologic alteration of tendon tissue, causing it to become more cartilaginous.

Moderate (40 N) and high (60 N) cyclic loads are reported to create an acute neuromuscular disorder characterized by delayed hyperexcitability in the lower back. This delay is characteristic of an inflammatory state. Microtears within muscle tissue have been shown to be related to higher repetition loads and cyclic rate ¹⁸.

Psychosocial factors have been implicated in overuse injuries for decades ¹⁹. A partial list includes work satisfaction, perceived physical health, perceived mental health, coping mechanisms of the patient and his/her family, perception of work-readiness, and anxiety.

A review of the English-language literature revealed specific articles focusing on ultrasonographers, equestrian athletes, ballet dancers ²⁰, bicyclists, baseball players, swimmers, triathletes, golfers, bull riders, martial artists, sign language interpreters, skeletally immature patients ¹², college students, heavy computer users, assembly line workers, tailors (seamstresses), surgeons, dentists, and nurses. This list dramatizes the point that at least the perception exists that many common and some uncommon ailments are associated with repetitive motion.

Cumulative trauma disorder prevention

Making changes to the design of a workplace and workplace practices, and using adjustable furniture can reduce the risk of cumulative trauma disorder.

Changes to workplace design

Suggestions include:

• Use ergonomically designed furniture and equipment.
• Rearrange the workspace to keep everything needed within easy reach.
• Keep benches at waist height, so that shoulders can relax and arms can bend gently at the elbows.

Changes to work practices

Suggestions include:

• Schedule work to include frequent breaks.
• Vary tasks so that repetitive hand movements are alternated with other work.
• Set realistic deadlines.

Adjusting furniture to suit your body

Keyboard operators and typists are commonly at risk of developing cumulative trauma disorder. Furniture, such as chairs and desks, should be adjusted to suit the dimensions of the individual and support good posture.

Suggestions include:

• Adjust the height of your chair until your elbows are level with the keyboard.
• Use a chair with a lumbar (lower back) support.
• Keep document holders next to the computer screen, at the same viewing distance.
• Use a footstool to raise the level of your knees slightly higher than your hips, if you cannot make adjustments to your desk and chair.
• Locate the mouse close to the keyboard and use a mouse pad.
• When possible use regular-sized computers instead of smaller laptops.

Most overuse injuries are avoidable. To prevent an overuse injury:

• Regular stretching and strengthening exercises for your sport, fitness or work activity, as part of an overall physical conditioning program, can help to minimize your risk of muscle strains. Try to be in shape to play your sport; don’t play your sport to get in shape. If you have a physically demanding occupation, regular conditioning can help prevent injuries.
• Use proper form and gear. Whether you’re starting a new activity or you’ve been playing a sport for a long time, consider taking lessons. Using the correct technique is crucial to preventing overuse injuries. Also make sure you wear proper shoes for the activity. Consider replacing your shoes for every 250 to 500 miles you walk or run — or at least twice a year if you regularly exercise.
• Pace yourself. If you’re starting a new fitness program, avoid becoming a weekend warrior. Compressing your physical activity for the week into two days can lead to an overuse injury. Instead, aim for at least 30 minutes of moderate physical activity a day. If you don’t have time for a full 30 minutes, you can break it down into smaller blocks of activity throughout the day. It’s also a good idea to take time to warm up before physical activity and cool down afterward.
• Gradually increase your activity level. When changing the intensity or duration of a physical activity, do so gradually. For example, if you want to increase the amount of weight you’re using while strength training, increase it by no more than 10 percent each week until you reach your new goal.
• Mix up your routine with cross-training. Instead of focusing on one type of exercise, build variety into your fitness program. Incorporating a variety of low-impact activities — such as walking, biking, swimming and water jogging — can help prevent overuse injuries by allowing your body to use different muscle groups and not overload any one particular group.

And be sure to include strength training for the major muscle groups in your arms, legs and core at least twice a week.

Cumulative trauma disorder symptoms

Occupational cumulative trauma disorder is usually associated with repetitive hand movements such as typing, but any part of the body can be affected. Overuse syndrome can affect the tendons and muscles of the fingers, hands, wrists, elbows, shoulders, back and neck.

Overuse syndrome symptoms vary, depending on the individual, the site of injury and the severity of the condition. At the beginning, your arms and hands will just feel tired and fatigued, which you may think is normal. Then, you may begin to feel musculoskeletal pain, meaning pain in your muscles, bones, ligaments, tendons and nerves. If it continues to get worse, you could be dealing with microtrauma, which occurs when small parts of your soft tissue begin to tear. Eventually, your muscles and tissues will experience more and more trauma, resulting in pain and loss of use.

Common cumulative trauma disorder symptoms may include:

• pain
• muscle weakness
• swelling
• numbness
• restricted mobility of the joint
• gradual loss of the ability to move your hands and/or arms like you once could.

Tenderness and guarding are often present in overuse injury. Other signs and symptoms may include a history of popping, clicking, rubbing, erythema, or vascular phenomena ²¹.

It is not possible to ‘work through’ cumulative trauma disorder. Initially the pain and stiffness may be slight and only noticeable while the particular manual task is performed. If these symptoms are ignored the discomfort will escalate until the joints, muscles and tendons are painful even when at rest.

Cumulative trauma disorder diagnosis

During the physical exam, your doctor will check for swelling, points of tenderness and passive and active range of motion (ROM). The location and intensity of your pain can help determine the extent and nature of the damage. Tenderness and guarding are often present. Crepitus, either painful or painless, is often found during the ROM examination. Obvious erythema, swelling, and anatomic derangement raise the possibility of an acute injury or infection, as well as the presence of an inflammatory disease ²².

In more severe injuries, where the muscle or tendon has been completely ruptured, your doctor may be able to see or feel a defect in the area of injury. Ultrasound often can help distinguish among several different types of soft tissue injuries.

Imaging studies

The diagnosis of most overuse injuries does not require imaging studies. However, if surgical intervention is considered, imaging studies are vital for the decision-making process.

Radiography

Bony avulsions are relatively common among people who participate in dance, athletic activity, and heavy physical labor. Radiography is useful for defining these bony avulsions.

Stress fractures; calcification of tendons, which occurs in persons with chronic tendonitis; joint mice; myositis ossificans; heterotopic ossification; and atrophy of cartilage generally are revealed with radiography.

Bone scanning

This may reveal stress fractures that are not evident on radiographs.

Magnetic resonance imaging (MRI)

Typically, MRI is more effective for acute injuries; findings are generally more subtle with chronic injuries.

MRI is increasingly effective for revealing the site of nerve compression when large nerves are involved (eg, ulnar, median, sciatic), but it is not yet definitive for smaller nerves. Its true sensitivity is still being determined for these uses.

MRI has been quite successful in revealing tendon, ligament, and muscle injuries. It is easily available, does not involve radiation, and can help to assess chronicity of soft-tissue injuries.

The presence of bone marrow edema on MRI scans may precede visualization of stress fractures of the cortical bone and indicates trauma to the trabecular portions of the bone.

Banks and colleagues ²³ published a review of MRI findings in athletes’ overuse injuries.

Ultrasonography

In the hands of a skilled clinician, ultrasound can be a quick and effective method in the clinic to assess for fluid collections, impingements, and/or soft tissue tears associated with many overuse injuries. However, ultrasound typically is not utilized as much in the surgical planning process as the aforementioned imaging modalities.

Laboratory studies

Laboratory tests are rarely contributory to the evaluation of overuse injury, and no laboratory results contribute to the diagnosis of overuse injury. However, several tests are generally ordered during the initial workup to rule out other etiologies of pain, depending on the patient’s presentation, including, but not limited to, the following:

• Erythrocyte sedimentation rate (ESR)
• Rapid plasma reagent testing (RPR)
• Antinuclear antibody testing (ANA)
• C-reactive protein (CRP)
• Complete blood count (CBC)
• Vitamin B12
• Thyroid-stimulating hormone (TSH)
• Comprehensive metabolic panel (CMP)

Electrodiagnostic testing

Electrodiagnostic testing (eg, electromyography (EMG), nerve conduction studies) can be very useful when employed in the appropriate scenarios. In cases of peripheral nerve compression or injury, such testing can provide evidence of the location and severity of the injury. Electromyography (EMG) and nerve conduction studies are not tests with high specificity, although they can provide much-needed information when vague symptoms are the chief complaint. They are also very useful for documenting work-related injuries.

Cumulative trauma disorder treatment

Relative rest, particularly avoidance of the inciting activity, is a hallmark component of treatment. Using the involved area in nonpainful ways often helps to maintain range of motion (ROM). Total bed rest is virtually never advisable for these patients. Participation in a carefully planned physical therapy program is important for the following reasons:

• Patient education
• Supervised use of the injured part ²⁴
• Appropriate use of modalities (eg, transcutaneous electrical nerve stimulation units, similar electrical treatments, ultrasound/phonophoresis, iontophoresis, heat/cold)
• Development of a home exercise program
• Psychosocial benefits related to frequent interaction with an active partner in the treatment regimen

In a randomized clinical trial ²⁵, the short- and long-term effect of an exercise training program used for treating adductor-related groin pain in athletes was evaluated. The program had 47 participants who agreed to be interviewed and examined in an 8- to 12-year follow-up. The results found that the exercise program had a long-lasting effect on the participants and is the first time an exercise treatment program for overuse injuries to the musculoskeletal system has had this significant of an outcome ²⁵.

The physical therapy program also offers the patient the chance to see that movement will not lead to ongoing tissue damage, thus preventing significant “sick behaviors” or kinesophobia.

Overuse injury in athletes is commonly caused by ill-fitting equipment (eg, in cycling), overtraining/overreaching (eg, with regard to triathlons, marathons, etc), or technique flaws ²⁶. Specialized bike-fitting is available, sports psychology is worthwhile in combating overtraining, and sport-specific coaching is often invaluable. Coaches, athletes, and physicians must work together to correct these problems and maintain a healthy musculoskeletal system.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are mainstays in the conservative treatment of overuse injuries. However, considerable evidence has been revealed that true inflammation is rarely a component of these disorders, especially tendinopathies. Consequently, the use of simple analgesics has become more prevalent in the treatment of such disorders.

Muscle relaxants, opiates, corticosteroids, tricyclic antidepressants, and sleep medications have a role in the tailored treatment of individuals with overuse injury.

Occupational therapy

Occupational therapists with experience in this field can help to identify workplace modifications. In cases of individuals with disabilities who develop overuse injuries as a result of the interface with adaptive equipment, occupational therapy may be of great benefit. Often, simple modifications in the manner in which the patient performs activities of daily living or modifications in the equipment itself confer relief.

Vocational rehabilitation and work-hardening programs are often effective for bringing motivated patients back into the workforce. Integration of this type of program has proven to be effective in the corporate world and has decreased the overall financial impact of overuse injuries in the workplace.

Medical therapy

Injection of involved structures with combinations of corticosteroids and local anesthetics is frequently quite helpful in persons with overuse injuries. Pain relief enables more effective participation in therapy, and it may help to limit the likelihood that the patient will develop a chronic pain syndrome. In most cases, injections should be performed after less invasive measures fail.

Steroid injections are the most commonly used procedure in the treatment of overuse injuries, although controversy surrounding this treatment is still readily apparent. Tendons and ligaments can become structurally weakened by the use of steroids, predisposing them to rupture. The use of local anesthetics and steroids should be reserved for patients with significant pain who have the ability to change the underlying cause behind their injury. Repeatedly injecting patients who will inevitably return to the same routine that initially caused the injury is not advisable ⁶.

Many steroid injections can be performed under ultrasonographic guidance to increase accuracy and decrease the possibility of intratendon or intraligament injection.

Rarely, immediate relief of pain may be necessary to allow participation in an athletic or performing arts event, and this can be achieved through injection therapy.

Surgical intervention

Surgical intervention is undertaken if conservative approaches fail and if the injury is amenable to surgery. Decompression of nerves and repair of lax or failed ligaments are the most common overuse injuries that lead to surgery. Surgeries that are performed solely to relieve pain in the absence of objective findings are notorious for suboptimal outcomes.

You will likely have a physical or occupational therapist who can help you recover after the surgery. They’ll teach you some different range of motion exercises that will help you regain normal functionality in either your hand or arms.

When you’re ready, you can start performing strengthening exercises to further improve how your hand and/or arm functions.

Cumulative trauma disorder prognosis

Most overuse injuries resolve after 3-6 months. However, unless the offending causes are addressed, recurrences are quite common. Patient motivation and commitment to prevention are key to rehabilitating these injuries.

Home exercise programs tailored to the individual’s biomechanics are another important facet of treatment.

Recovery after surgery varies depending on the procedure.

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