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Safeguard OSH Solutions - Thomson Reuters

Safeguard OSH Solutions - Thomson Reuters

Safeguard Magazine

Don’t dump, diagnose!

Before we can treat arm pain we must know what we’re dealing with, a hand surgeon tells JACKIE BROWN-HAYSOM.

“Occupational overuse syndrome doesn’t exist.

“It’s not a diagnosis – just a dumping ground, a licence to stop thinking.

“We need to be looking at the pathology, determining what’s truly wrong at a tissue anatomy level.”

After 15 years studying the biomechanics of the forearm, Auckland-based hand and orthopaedic surgeon Michael Boland has little patience with the widely accepted practice of labelling gradual process arm and shoulder pain as OOS.

“They say you have OOS? No you don’t. You have tendonitis, or nerve compression, or muscle fatigue, or something neck-related.

“The pathology is going to be in the tendons and their surrounding structures, or in the nerves and their surrounding structures, or in the joints or muscles.”

Traditionally, Boland says, both general orthopaedic surgeons and hand-and-wrist specialists have paid little attention to the area between elbow and wrist, even though a lot of so-called OOS pain is associated with this area.

“The forearm is a mobile structure, and, now that we are understanding how this amazing structure actually works, we’re finding it’s not the way we thought it was.”

Occupational physicians – and ACC – often reject claims that arm and shoulder pain in people such as computer users or hairdressers can be attributed to work-related injury, because the jobs don’t involve forceful movement. Boland, however, says it is now apparent that there is a different mechanism at work, creating injuries that, if correctly diagnosed, can often be successfully treated.

The problems arise, he says, because a lot of work involves prolonged activity with the underside of the forearm and palm facing downwards – a position known as pronation. The resting position for the forearm is mid-pronation, with the forearm turned towards the body at a 45° angle. At full pronation, however, muscles and tendons are taut.

“What we’ve created in modern society is something I call the Pronation Generation.

“We do everything with our palms down, which is not desirable.

“Add in repetitive ulna deviation of the wrist [turning the hand outwards – the motion used to hit the Enter key on a conventional keyboard] and thumb motion [to hit the space bar] and the muscles and tendons of the arm are working at an extreme mechanical disadvantage.”

The tendon that abducts the thumb [moves it downwards] crosses the wrist from the outer side, through a narrow tunnel. Repetitive thumb movement creates a situation that Boland compares to a piece of rope sliding backwards and forwards over a metal bar. This, he says, creates friction that can damage the synovium [the structure around the tendon], causing tendonitis.

“You can’t tell me, if you take these simple philosophies together, that typing isn’t contributing to the problems that we’re seeing.

“But if you take any occupation that’s overworking in pronation, and add in wrist, thumb or other motions, you’re going to see tendon-related issues.

“For instance, if what you’re doing all day involves extension of the wrist [flicking the hand upwards] in pronation, you’re overworking the same tendon that gets damaged with so-called tennis elbow.”

The potential for damage is not limited to tendons, however. The radial nerve, which passes beneath the forearm muscle that both bends the elbow and prevents over-pronation, is also vulnerable.

“If you are over-pronating, this muscle will be firing too much, so it will press down on the nerve, causing radial tunnel syndrome. And again, the crux of the issue is pronation.”

There are, Boland says, good logical reasons why someone like a typist or a hairdresser could be expected to suffer radial nerve compression, but because there is, as yet, little or no confirmation of this in the medical literature, occupational physicians are unlikely to make this diagnosis.

“For that to happen you’d need doctors who truly understood radial tunnel syndrome. At the moment I would say there are probably five in New Zealand who do, and none of them are occupational physicians.

“So for an occupational physician to tell me that radial tunnel syndrome is not caused by repetitive over-pronation of the wrist in a hairdresser is a slap in the face.”

The medical profession as a whole needs a more open mind to things they do not understand, he says.

“Occupational overuse syndrome shouldn’t be a dumping ground.

“If you’re a professional tennis player with wrist pain they won’t say you have OOS, even though it’s your occupation, and the pain has been caused by overusing your wrist.

“But if they’re not prepared to give that diagnosis to Roger Federer, why should they give it to a typist? Everyone should be treated the same – get to the bottom of the problem, and organise a way to help them out.”

It frustrates Boland that ACC uses non-specific terms, such as wrist pain, as diagnostic codes.

“Wrist pain isn’t a diagnosis. It’s the first step in the process – not the end point.

“If you don’t understand wrist pain you send them to somebody who does.”

He’s keen to see ACC improve its processes too, believing a swift referral to the right specialist would result in better care.

“At the moment a client can see 15 doctors, four lawyers, and three psychiatrists before they end up where they really need to be.

“What ACC needs is a huge database so it can say: ‘Chronic anterior knee pain goes by Dr X, who’s in sports medicine in Auckland.’ With early specialist intervention you’ll get to the root causes of problems faster.”

Because of the prevalence of arm pain, and the low numbers of hand surgeons, he suggests that specially trained hand therapists could assist with the early diagnosis of work-related upper limb conditions.

“If you’re going to deal with this you need to understand the anatomy, understand the pathology, understand what may be causing that pathology – and understand that occupational overuse syndrome is not a licence to stop thinking.

“And you need to have empathy, so people don’t go away feeling like they’ve been wasting your time. That’s the nuts and bolts of it.”


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