The Role of Chronic Soft Tissue Overload Syndrome and Lower Workers Comp Costs

We are very fortunate to be associated with some very fine, knowledgeable persons who provide excellent insight into the various topics we constantly highlight in bringing our readers and clients cost effective ways of reducing workers compensation costs.

On such person is Alice M Martinson, M.D., a board-certified orthopaedic surgeon and former Naval Medical Officer. I recently interviewed “Dr. Alice” on the topic of chronic soft tissue and its effects on workers compensation.

This is a cluster of conditions that can develop in upper extremities which are used for rapidly-repetitive and/or forceful gripping activities.

If you want to abbreviate it, it’s most accurate to call it “chronic soft tissue overload syndrome” (CSTOS). Some people term it “repetitive stress syndrome,” but that seems a little vague to me. Repetitive stress of what?

CSTOS is characterized by a group of separately-identifiable conditions, all of which have names and all of which are related to each other by the presence of tenosynovial irritation from rapid fingering activities. The commonest of the conditions are:

1. Carpal Tunnel Syndrome

2. De Quervain’s “disease”

3. Trigger Fingers

4. Extensor Tenosynovitis on the dorsum of the wrist and forearm.

Conditions in the more proximal parts of the arms can appear in some employees as well. They are not related to tenosynovitis, but rather represent the consequences of prolonged periods of unrelieved fixed posture. The most common of these are:

1. Lateral Epicondylitis

2. Cubital Tunnel Syndrome (ulnar nerve compression at the elbow)

3. Postural Upper Backaches are the commonest examples of proximal problems.

In elbow problems, prolonged elbow flexion allows the extensor muscles to tighten and makes them more susceptible to strain (“lateral epicondylitis”). Prolonged elbow flexion keeps the ulnar nerve on stretch as it passes around the flexed elbow within the confines of the cubital tunnel. Sitting for a long time with shoulders hunched places the upper back muscles on stretch so that when there is concentration or tension, burning pain develops adjacent to the shoulder blades. Think accountants in the couple of months before tax time.

For many years it was the forceful-grip industries experiencing the condition the most – meat/ poultry processing and automobile or airplane assembly. When the objects gripped were vibrating tools, the problems arose faster than in other pure grip activities. Now that computer keyboarding and mouse use are so widespread, most of the problems seem to be arising in those jobs requiring constant activities of that sort in both Federal employment and private industry.

In Federal service I’ve seen it most in IRS customer service representatives, who spend their entire workday on the computer. Certain kinds of postal work can be highly repetitive as well. Customer service representatives in telecommunications and other similar private industries seem to be quite commonly affected. The common denominator is rapidly-repetitive use of the hands for extended periods, and/or in fixed postures. That means the condition is also very common in professional musicians as well – particularly violinists and woodwind players.

Chronic illnesses also can have a major impact on these conditions. Diabetes, thyroid disease, gout, and rheumatoid arthritis are good examples. The fluid accumulation during pregnancy is well-known to precipitate carpal tunnel syndrome, even in non-repetitive situations. These non-work related conditions do NOT cause CSTOS, but they do influence the progression and severity or the conditions once they develop.

My active duty career ended just as computers were starting to become ubiquitous. My recollection is that the heavy-duty specialties such as machinists’ mate, boiler tender, and other similar ratings were the ones most commonly affected most commonly. Now, in the computer era, I would expect any of the ratings using computers extensively will see it. Fortunately the individuals in highly-stressful jobs such as radar, sonar, and fire-control technicians typically serve for only several hours at a time. That protects the soft tissues as well as ensuring fatigue doesn’t degrade critical performance.

Orthopaedic surgeons primarily treat these conditions, although plastic surgeons specializing in hand surgery treat them as well. Ideally early appreciation and insightful intervention will allow these conditions to be treated non-surgically. Carpal or cubital tunnel problems, triggering fingers, and tenosynovitis of the thumb abductors can sometimes be settled down with corticosteroid injections, but if they cannot, there are simple and safe surgical procedures available to treat these conditions.

Repetitive hand use jobs can’t really be changed that much. Employers can, however, ensure that their employees have proper ergonomic environments. In the meat packing industries, this means keeping knives and scissors very sharp so that the force of grip can be diminished.

In keyboarding jobs, it means keyboards and screens are at proper height to allow proper employee posture. Taking frequent “mini-breaks” is a strategy used by musicians with great success, and one that can be used successfully by keyboarders as well. Those breaks are built into most compositions but musicians get into trouble during intense unrelieved periods of hard practice.

Frequent stretching of the tendons of the forearm and hand is very useful, as is the practice of postural stretching exercises for the shoulder girdles. It doesn’t have to be for long periods; typical minibreaks will be useful if they are no longer than about 30 seconds and are repeated every 15 minutes or so.

Splinting for carpal tunnel syndrome – particularly at night is very useful. It’s next to impossible to work in a splint, however, if you ever need to try, go to the bowling alley, and get a bowler’s brace. It’s cut differently since it must be used to hold the ball hold, the beer, and the pencil for scoring. What splints do is keep the wrist out of prolonged flexion. That’s the position that pulls the maximum volume of tissue into the carpal canal, and it’s the position we all tend to assume during sleep. That’s why waking up at night with burning paresthesias in the fingers is a very common – almost diagnostic – part of the patient’s history in carpal tunnel syndrome.

Every individual’s soft tissues have different tolerance for highly repetitious activities. This appears to be an inborn biologic characteristic. Some employees will tolerate rapidly repetitive jobs for a number of years, while others will develop progressive symptoms is as short a time as two weeks. Once one of the soft tissue overload conditions appears, it can be successfully treated; but if the individual returns to the same job with the same poor ergonomics, another of the constellation of conditions will develop – and in less time than it took for the first one to appear. The employer can make the necessary ergonomic and scheduling modifications, but motivation plays a major role in individuals’ ability to resume their repetitive jobs successfully.

That’s a hard question to answer, since it varies depending on the syndrome being treated and its severity. The diagnosis itself is NOT a good reason to take an individual off work. Minimizing time off keeps employees engaged with their employment and doesn’t allow the secondary gain of “illness” to take root.

When surgery is involved, most employees should be able to return to some sort of modified work within three to four weeks of the procedure. Frankly, the lost time from work has a great deal to do with an employer’s response to the employee’s complaints. In highly repetitive and unskilled jobs, employers are much less motivated to make the necessary adjustments or modifications, since the position can be filled by a new hire without sacrificing any investment in employee training.

Much as employers would like not to believe it, the condition is real. It can be managed, but ignoring it will not make it go away. There is a lot of partial or misinformation circulating among employees in industry where the conditions are frequently seen.

The three most important things for prevention and control of the decreased productivity resulting from these conditions are: (1) A proactive program of employee and supervisor education; (2) attention to the ergonomics of the workspace; and (3) fostering a corporate environment where employees do not feel threatened when reporting a condition.

Author: Alice M Martinson, MD has practiced for 40 years as a board-certified orthopaedic surgeon, 25 of which were as a Naval Medical Officer. Relying on her extensive military experience with injury evaluation, she performs IMEs and consults on loss control issues. Contact: 870-480-7475 or [email protected]. To read more about “Doc Alice,” go to:

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