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June 13, 2011

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Musculoskeletal disorders – Repeat gains

Repetitive Strain Injuries have been diagnosed and treated for many years, but, cautions Dr Tony Kochhar, they are now on the rise owing to a combination of economic and technological factors. Employers wishing to manage these emerging risks should read on.

Fears relating to job security, house prices, cuts in public services and retirement funding are causing us all to work harder and longer hours. Faced with such pressures, it is understandable why some would believe any impact of Repetitive Strain Injuries (RSIs) to be trivial. Indeed, I often come across a belief that RSI has ‘gone away’, while there are those who, despite the evidence, never really believed it existed in the first place.

Because of such beliefs and a tangible sense that RSIs are no longer ‘fashionable’, I know occupational-health professionals and others can sometimes struggle to ensure this risk is managed effectively and proportionately.
There are, of course, ‘definition issues’ – both in what really constitutes RSI and how it is recorded. For example, the HSE measures upper-limb or neck issues under a broader category of musculoskeletal disorders (MSD). What data does exist is also, for perfectly understandable reasons, gathered mainly through the employee self-reported illness survey conducted by the HSE.

Nevertheless, thanks to the excellent work of the Executive, there are certain things we do know. For example, in 2009/10 – the latest figures available – some 230,000 people reported upper-limb issues (the most likely area to suffer from RSIs), or 770 per 100,000 employed in the last 12 months. This represents around an 8-per-cent increase on last year’s figure of 710 per 100,000 employed.1 We also know that upper-limb issues led to the loss of 3.6 million working days in the UK during 2009/10, and 3.7m during 2008/9.2

Of course, some complaints in this category may not be RSIs but, equally, it could be suggested that a proportion of, say, back complaints could be RSI-related, along with other MSD areas.

Over the last year, in my own practice, I’ve seen a 30-per-cent rise in patients presenting with RSIs. When I interact with online communities, such as mumsnet, I’m surprised by the number of responses and interest there is from RSI sufferers. Given I am just one of many specialists in this field, it does raise an interesting question of just how prevalent RSIs truly are, both in the workplace and wider community?

The modern relevance of managing RSI as a workplace risk was also highlighted by a recent RSI compensation case brought in the High Court by two former employers of a well-known international airline.3  

Taking all the above figures together, there is a compelling case for asking whether any employer can really afford to take this condition lightly. Equally, such stories and statistics should serve as an opportunity to convince any doubting employer that this is very much a live issue that needs addressing.

Indeed, through my daily work with patients, patient groups, legal experts and occupational-health professionals, I have come to notice how many of these situations could have been prevented with some simple advice, or at least minimised by the organisation taking appropriate action. 

Such an approach not only ticks the relevant boxes for providing “reasonable and practicable” adjustments in the workplace to accommodate a medical condition, but it also prevents unnecessary suffering in the first place – as so many RSI conditions are easily alleviated by small changes to workstations, or working practices. Taking all this on board, the following Q&A guide on how to redress and prevent RSI is offered.

What is RSI and why is it rising?

Repetitive strain injury (RSI) is a term used to describe a broad range of symptoms caused by the repeated movement of a particular part of the body. RSIs are also known as Work-related Upper-Limb Disorders (WRULD), Repetitive Stress Injury, and Cumulative Trauma Disorder.

It usually affects the upper limb (shoulder, elbow, wrist, or hand) and can be caused by any repeated activity, including sports and pastimes. Recent advances in technology, such as smartphones, handheld video games, and even hair-straighteners have led to a new wave of RSI problems. They are, nevertheless, mainly attributed to activities in the workplace.

RSI almost always tends to start as a minor ache. This is largely because it can affect nerves, muscles, tendons, tendon sheets, bones and joints – either in isolation, or in combination. 

This initial slight annoyance is usually overlooked and no treatment is given, allowing the tissue irritation and damage to progress. Pain worsens, first at rest and then at night, affecting the individual’s sleep. Finally, an acute problem becomes a chronic condition.

When looking for an explanation as to why this occurs, two factors need to be taken into account. The first is that the ability for a tissue to heal is dependent on its blood supply. The tissues and structures involved in RSIs (tendons, tendon sheaths, capsules, ligaments, nerves) generally have very poor blood supplies. Therefore, they heal very slowly and respond poorly to injury. Secondly, as defined by its name, a Repetitive Strain Injury occurs each time that activity is performed. If, for example, the use of a computer mouse irritates the tendons around the wrist, it only gets worse when the individual uses the mouse again.

In the early stages of any of these conditions, if we could rest the tissues fully, the problem would settle on its own. However, because the healing potential of these tissues is poor, one would have to cease the provocative activity for an awfully long period of time. Also, once an area is irritated, movements that use the wrist continue to cause damage, even if the exact activity has been stopped. Consider, for example, a personal assistant who develops irritation of their wrist tendons by long hours of typing. Once diagnosed, they stop typing, but the symptoms do not necessarily settle because all other activities (e.g. use of a mouse, telephone, smartphone, writing) continue to involve use of the same irritated wrist.

These complexities can be compounded by the fact that, even today, understanding of RSIs can be poor, resulting in poor treatment. Even where treatment is offered, it usually, in the first stage, amounts to physiotherapy. But unless this treatment is accompanied by changes in working practices, over the long term, it may prove ineffective and therefore lead to a worsening of symptoms to the point where they become chronic.

In today’s working environment, where we are all working harder and longer hours, I see many patients for whom a change in working practices is not possible without support from a manager, or their colleagues in the department. Ultimately, understanding and treating RSI is as much an issue of educating a workforce as it is about treating the individual patient. 

Are there different types of RSI?

Broadly speaking, there are two RSI conditions. Type 1 conditions include well-defined syndromes such as Carpal Tunnel Syndrome, DeQuervain’s Tenosynovitis, Cubital Tunnel Syndrome, Olecranon Bursitis and Ganglion formation. These conditions may be due to, or made worse by, repetitive tasks. They may also have other symptoms, such as swelling, inflammation, nerve-compression problems, etc. These discrete orthopaedic problems are often easier to diagnose but, typically, only once the condition is long-standing.

The second type of RSI condition is less specific. These tend to present as deep, non-specific aching pains and episodes of tingling and neurogenic (i.e. originating from nerves and characterised by often sharp, electric pain and abnormal sensations) pain symptoms that are difficult to define. Recent studies suggest that repetitive movements cause traction on peripheral nerves, leading to these symptoms. Other research suggests that these conditions are myofascial in origin (i.e. affect the sheets of tissue that divide and connect groups of muscles in the arm). Most difficult to treat are type 2 conditions, where multiple tissues are affected.

Successful treatment may require input from a doctor, surgeon, pain specialist, physiotherapist, hand specialist, psychologist, and vocational rehabilitation specialist, while the recovery may take longer and be more complex.

What are the tell-tale signs of RSI?

It can’t be stressed enough that if, either as an employer or employee, you believe that you or your colleagues are experiencing RSI conditions, then you should seek advice from your GP.

That said, there are some key ‘red flag’ symptoms of RSI, to which employers and colleagues should be alert to, and these are discussed below.

Tingling in the fingers – this can be very common in patients suffering with RSI. The sensation is usually due to compression on a nerve, such as in Carpal Tunnel Syndrome. Poor wrist posture while typing reduces the space in the carpal tunnel, and the repetitive action of typing leads to irritation of the median nerve. This causes the classic symptoms of tingling in the tips of the fingers of the thumb, index finger and middle finger. It can be quite painful, especially at night and, if left untreated, can lead to permanent disability.

Deep aching pain in the wrist – this occurs especially in people who type a lot and is often worse at the end of the day. The person often feels stiff in the morning, the wrist loosens up to lunchtime, and then aches in the afternoon. This ebb and flow of symptoms disappears as the condition worsens and may develop into constant pain, even at rest.

Pain when getting dressed – especially in the case of shoulder conditions (impingement syndrome of the rotator cuff tendon), people often have difficulties. Interestingly, there is a ‘RSI gender gap’ – for example, women often report having to clip their bra on at the front and then slide it round, while men have pain when putting on their jacket, tending, as they do, to put their ‘bad arm’ in the sleeve first.

Shoulder impingement – this can start as a catching pain when performing certain movements, e.g. lifting an object into an overhead position. To illustrate how widespread this situation can be, it affects employees in diverse sectors, including aviation, painting and electrical-contractor industries. For example:

  • aircraft cabin crew regularly have to stow hand luggage in overhead lockers, or fit lights;
  • painters, often for long periods of time, are required to decorate ceilings, attach covings and ceiling ‘roses’; and
  • electricians frequently work above shoulder height, attaching light fittings.

The list of manual workers – plasterers, baggage handlers, train and bus workers, for example – can easily be extended, before we even begin to examine more office-based roles linked to RSIs. Clearly, shoulder impingement can affect anyone whose working pattern involves lifting and carrying, and employers really need to think through how they can minimise or, ideally, prevent such situations.

Aching over the outside of the elbow – this is worse when typing, or lifting even light objects, such as a cup of tea. Tennis elbow (lateral epicondylitis) often presents in this way. There is often tenderness (pain when pressing) on the outer tip of the elbow, and other symptoms include a deep aching pain along the back of the forearm when typing, or lifting objects. You don’t have to play tennis to develop tennis elbow! It develops because the small muscles in the back of the forearm, which help us lift objects when we pick them up, become overloaded.

Lumps and bumps – when tissues become irritated or damaged, they become swollen. This is often accompanied by a feeling of warmth and tenderness (but painful when you press on the area). Specific swellings can develop from RSIs – for example, a ganglion can develop around the wrist (especially the back and thumb side). This is a herniation (outpouching) of the lining of the wrist joint. It can be unsightly, painful and affect many activities. Over the back of the elbow, an olecranon bursa may develop, possibly following repeated pressure on the tip of the elbow.


RSIs are still very much relevant and, from my experiences and interpretation of both official figures and other sources, they are rising significantly. This can largely be attributed to increased use of workplace-related mobile technologies, and because those people in employment are working harder and longer at their keyboards and at other tasks that can cause such injury.


Dr Tony Kochhar is a consultant orthopaedic surgeon, specialising in the treatment of RSIs.

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11 years ago

Hi Dr Kochhar, On the internet I can’t find any recent up dates for the treatment of RSI. Would you have any references please? I am particularly interested in prevention.