Repetitive strain injury Maurits van Tulder, Antti Malmivaara, Bart Koes Repetitive strain injury remains a controversial topic. The term repetitive strain injury includes speciﬁ c disorders such Lancet 2007; 369: 1815–22 as carpal tunnel syndrome, cubital tunnel syndrome, Guyon canal syndrome, lateral epicondylitis, and tendonitis of Institute for Research in the wrist or hand. The diagnosis is usually made on the basis of history and clinical examination. Large high-quality Extramural Medicine, VU studies using newer imaging techniques, such as MRI and ultrasonography are few. Consequently, the role of such University Medical Centre
(Prof M van Tulder PhD) and imaging in diagnosis of upper limb disorders remains unclear. In many cases, no speciﬁ c diagnosis can be established Institute of Health Sciences, and complaints are labelled as non-speciﬁ c. Little is known about the eﬀ ectiveness of treatment options for upper limb Faculty of Earth & Life Sciences, disorders. Strong evidence for any intervention is scarce and the eﬀ ect, if any, is mainly short-term pain relief. Exercise VU University, Amsterdam, is beneﬁ cial for non-speciﬁ c upper limb disorders. Immobilising hand braces and open carpal tunnel surgery release Netherlands (Prof M van Tulder); Finnish Oﬃ ce for Health Care are beneﬁ cial for carpal tunnel syndrome, and topical and oral non-steroidal anti-inﬂ ammatory drugs, and corticosteroid Technology Assessment, injections are helpful for lateral epicondylitis. Exercise is probably beneﬁ cial for neck pain, as are corticosteroid Helsinki, Finland injections and exercise for shoulder pain. Although upper limb disorders occur frequently in the working population, (A Malmivaara MD); and most trials have not exclusively included a working population or assessed eﬀ ects on work-related outcomes. Further Deptartment of General Practice, Erasmus MC, high-quality trials should aim to include suﬃ cient sample sizes, working populations, and work-related outcomes. University Medical Centre Rotterdam, Rotterdam, the
Repetitive strain injury is not one diagnosis, but is an example, high rates of this disorder have been reported in Netherlands (Prof B Koes PhD) umbrella term for disorders that develop as a result of men employed in industries manufacturing textiles, Correspondence to: repetitive movements, awkward postures, sustained force,
footwear, food, and beverages. High rates were also seen in Prof Maurits van Tulder, Institute
and other risk factors.1 Epidemiological studies have women working in manufacturing of basic metal, food Medicine, VU University Medical shown that psychosocial workplace factors such as low and beverages, textiles, clothing, and footwear.8,34 In the Centre, 1081 BT, Amsterdam, deci
sion latitude (employees having little control over Netherlands, the professions with highest risk of repetitive Netherlands
their working practices or conditions), psychological strain injury include tailors, dressmakers, construction firstname.lastname@example.org distress, mono tonous work, and poor relationships within
workers, secretaries, typists, people who use visual display
the workplace are also associated with symptoms of units, and those who load, unload, or pack goods.6 The repetitive strain injury.2 Although this disorder is common
economic burden of repetitive strain injury is large,
in people who work, and occupation-related factors are especially because of the high costs associated with absence associated with an increased risk of its development, from work. The mean costs of a worker’s compensation factors not related to work can also play a part, and it is claim for this disorder range from $5000 to $8000 and total common in the general population. The term repetitive $6·5 billion every year in the USA.35 Several factors that strain injury is controversial and other descriptive terms increase the risk of repetitive strain injury have been for the symptoms have been suggested, such as cumulative
ed, and can be categorised into physical,
trauma disorders, occupational cervicobrachial disorders,
psychosocial, and individual risk factors.36
occupational overuse syndrome, upper extremity Ample evidence exists for the association between musculoskeletal disorders, upper limb dis
orders, and physical risk factors such as repetitive movements, poor
posture, and inadequate strength and the occurrence of repetitive strain injury. The eﬀ ects of work-related and
psychosocial factors are not as clear as those of physical
Repetitive strain injury arises frequently in adults of factors, although high workload, stress, and physical or working age, with many people reporting strains of the hands, wrists, arms, shoulders, or neck. Repetitive strain injury complaints are common in the general population
Search strategy and selection criteria
and are a frequent reason for visiting the general
We searched Pubmed, Embase and the Cochrane Library from the dates that these
practitioner.9 Several countries report a prevalence of 5–10%
databases begin up to December, 2005, for studies on pathophysiology, epidemiology,
for non-speciﬁ c complaints of strain that interferes with
prognosis, diagnosis, and treatment of repetitive strain injury. Detailed search strategies for
day-to-day activities,10–13 but rates could be as high as
diagnostic and therapeutic studies are available from the corresponding author. Studies
22–40% in speciﬁ c working populations.14–30 A large UK
about pathophysiology, epidemiology and prognosis were identiﬁ ed by use of the MESH
study (9696 people) reported frequencies of lateral
terms or free text words: “pathophysiology”, “epidemiology”, “incidence”, “prevalence”,
epicondylitis (1·3% in men and 1·1% in women), de
“prognosis”, and “prognostic factors”. Clinical Evidence (issue 14, December, 2005) was
Quervain’s disease (0·5% in men and 1·3% in women),
screened for additional systematic reviews and subsequent trials.5–8 No additional studies
and tenosynovitis of the hand or wrist (1·1% in men and
were identiﬁ ed in the Cochrane controlled trials register. We included studies of adults
2·2% in women).31 Other studies have reported prevalence
diagnosed with any type of speciﬁ c or non-speciﬁ c repetitive strain injury, work-related or
rates of carpal tunnel syndrome of 7–14·5%.16,25,32,33
not. We excluded studies on whiplash. No language restrictions were used in the search, but
Repetitive strain injury is most common in speciﬁ c
we were able to read and include only English, Dutch, Finnish, German, and French papers.
professions and industrial settings. In Australia, for
www.thelancet.comVol 369 May 26, 2007
psychological demands, low job security, and little support
for diagnosis of carpal tunnel syndrome, which supports
from colleagues might be important.2,14,36,37 The eﬀ ect of their widespread use.45,46 Electrodiagnostic tests such as individual factors is less clear, although a review38 of nerve conduction studies or electromyographs might also 56 studies noted that repetitive strain injury is reported be useful if clinical diagnosis is not clear, although their more frequently in women than in men. This ﬁ nding was diagnostic accuracy has not yet been proven in high-quality supported by three subsequent studies.14,37,39,40 The relative
importance of physical, psychosocial, and individual risk
The American College of Rheumatology has published
factors is unknown and strong conclusions from criteria for imaging choices in chronic epicondylitis.49 They epidemiological studies are hampered by heterogeneous advise that MRI can provide important diagnostic popu lations, exposures, and outcomes, and methodological
information for assessment of lateral epicondylitis, but
that ultrasonography is of little diagnostic value. However, a systematic review concluded50 that the assessment of
MRI ﬁ ndings in epicondylitis was questionable because
Several hypotheses for the pathophysiology of repetitive the diagnostic studies included were of low quality. strain injury exist, but none has been strongly supported Additionally, MRI is associated with high costs, and these by scientiﬁ c evidence. Despite initial distal presentation, images are unlikely to aﬀ ect treatment decisions or this disorder seems to be a diﬀ use neuromuscular illness.41
Mechanical (elastic deformation of connective tissue due
to increased pressure within muscles) and physiological repetitive strain injury. These systems diﬀ ered in the (electrochemical and metabolic imbalances) reactions disorders they included, the names given to the disorders, might cause damage to muscle tissue and lead to com-
and the criteria used to describe the disorders.52 Palmer
plaints of strain. Continuous contraction of muscles from and colleagues53 summarised three new approaches to long-term static load with insuﬃ
cient breaks could result classiﬁ cation of repetitive strain injury (table 1), which
in reduced local blood circulation and muscle fatigue. could be helpful for diagnosis. Consequently, pain sensors in the muscles could become
All proposed classiﬁ cations categorise repetitive strain
hypersensitive, leading to a pain response at low levels of injury into speciﬁ c and non-speciﬁ c disorders. Speciﬁ c stimulation. Other hypotheses suggest frequent co-con-
disorders can have symptoms mainly of pain, stiﬀ ness,
tractions in muscles or changes in proprioception as the tenderness, swelling, or paraesthesia in the neck, shoulder, source of injury.6,42
elbow, hand and wrist, or carpal tunnel.54 Non-speciﬁ c
Some researchers have suggested that overuse of tendons
repetitive strain is diagnosed by exclusion of speciﬁ c
by repetitive loading causes repetitive strain injury.43 Four diagnoses or pathologies. A structured examination has pathological mechanisms have been suggested for been developed for diagnosis and classiﬁ cation of repetitive tendonitis: decreased elasticity of the tendon; friction strain injuries, on the basis of one of the classiﬁ cation between tendon and tendon sheath; tendon fatigue; and systems in table 1.4 This examination had reasonable mechanically-induced local temperature increase.6 Most reliability in both a hospital setting and a community patients with true inﬂ ammatory tendonopathies have setting.53,55 At present, the usefulness of the other long-lasting symptoms of degeneration of collagen ﬁ bre classiﬁ cation systems is not known. structure.43
The function of peripheral nerves can be disrupted by Treatment
mechanical overload. In carpal tunnel syndrome, for Non-speciﬁ c work-related repetitive strain example, studies showed that speciﬁ c forearm, wrist, and Exercise therapy is a useful treatment for patients with ﬁ nger postures, moderate hand loads, and external non-speciﬁ c work-related repetitive strain presenting to pressure on the palm can increase carpal tunnel pressure primary care physicians or physiotherapists. Exercise (at least temporarily) to levels at which nerve health is seems to provide symptom relief and improve activities of threatened.44 Pressure in the surrounding tissue, reduced daily living.56–63 Manual therapy, such as osteopathy or elasticity, vibrations, and direct compression of the nerves chiropractic could be useful in some patients.56,64 If one could reduce nerve conduction.
kind of therapy does not reduce symptoms, multi-disciplinary rehabilitation programmes are recom mended,
although no strong evidence is available for such
No gold-standard tests for repetitive strain injury exist. In treatments.56,57,65,66 Other treatment options are available for most cases, diagnosis is made on the basis of history and non-speciﬁ
physical examination, including assessment of range of behavioural therapy,56 massage, 58,62,63,67 multi
motion of joints, hypermobility, muscle tenderness, pain, rehabilitation,68 energised splint (gives oﬀ high-voltage strength, and imbalance between right and left limbs.41
pulses),69 and ergonomic keyboards,60,70,71 but whether or
Some clinical tests are used for speciﬁ c disorders. For not these interventions are eﬀ ective is still unclear. Ability example, Phalen’s test, Tinel’s test, and measurement of to return to work and reduction of sick leave are important nerve conduction velocity are highly sensitive and speciﬁ c outcomes for the patient. However, in three studies of
www.thelancet.comVol 369 May 26, 2007 Harrington4 Sluiter3 Helliwell52
Radiating neck complaints: at least intermittent pain or stiﬀ ness in the
neck and pain or paraesthesia in one or more upper extremity regions, associated with head movements for more than 4 of the past 7 days and pain in upper extremity on active or passive cervical rotation
Rotator cuﬀ tendonitis: history of pain in the deltoid
Rotator cuﬀ syndrome: at least intermittent pain in the shoulder region
Tendonitis: limitation of abduction of the
region and pain on resisted active movement
without paraesthesia, which is worsened by active elevation of the upper
shoulder, painful arc on abduction of the
arm for more than 4 of the past 7 days and at least one other positive
shoulder, shoulder pain, sleep disturbance
rotation—infraspinatus; internal rotation—subscapularis) test: (a) pain on resisted shoulder abduction, external rotation, or internal Bicipital tendonitis: history of anterior shoulder pain and
rotation; (b) resisted elbow ﬂ exion; or (c) painful arc
pain on resisted active ﬂ exion or supination of the forearmCapsulitis: history of pain in the deltoid area and equal restriction of active and passive glenohumeral movement with capsular pattern (external rotation>abduction>internal rotation)
Lateral epicondylitis: epicondylar pain and epicondylar
Lateral or medial epicondylitis: at least intermittent, activity dependent
Lateral epicondylitis: pain or tenderness or
tenderness and pain on resisted extension of the wrist
pain localised around the lateral or medial epicondyle for more than 4 of
pain on loading relevant muscle at lateral
Medial epicondylitis: epicondylar pain and epicondylar
the past 7 days and local pain on resisted wrist extension (lateral) or wrist epicondyle
tenderness and pain on resisted ﬂ exion of the wrist
ﬂ exion (medial)Cubital tunnel syndrome: at least intermittent paraesthesia in the 4th and 5th digit, or both, or the ulnar border of the forearm, wrist, or hand for more than 4 of the past 7 days and a positive combined pressure and ﬂ exion testRadial tunnel syndrome: pain in the lateral elbow region or forearm muscle mass of wrist extensors/supinator or weakness on extending the wrist and ﬁ ngers for more than 4 of the past 7 days and tenderness in supinator region on palpation over the radial nerve 4–7 cm distal to the lateral epicondyle and at least one other positive test: (a) resisted forearm supination; or (b) resisted middle ﬁ nger extension
De Quervain’s disease: pain over the radial styloid and
De Quervain’s tenosynovitis: intermittent pain or tenderness localised
tender swelling of the extensor compartment and either
over the radial side of the wrist, which may radiate proximally to the
pain reproduced by resisted thumb extension or positive forearm or distally to the thumb for more than 4 of the past 7 days and at triggering, locking, or nodule on tendon Finkelstein test
least one other positive test: (a) Finkelstein’s test; (b) resisted thumb
located in ﬁ nger ﬂ exor or extensor tendon,
Tenosynovitis: pain on movement localised to the
extension; or (c) resisted thumb abduction
or thumb ﬂ exor, extensor, or abductor
tendon sheaths of the wrist and reproduction of pain by
Peritendonitis or tenosynovitis: intermittent pain or ache in the ventral or tendon
dorsal forearm or wrist region for more than 4 of the past 7 days and provocation of symptoms during resisted movement of the muscles under the symptom area and reproduction of pain during palpation of the aﬀ ected tendons or palpable crepitus under symptom area or visible swelling of dorsum wrist or forearmGuyon’s canal syndrome: intermittent paraesthesia in the palmar ulnar nerve distribution of the hand, distal to the wrist or pain in the ulnar innervated area of the hand, which may radiate to the forearm for more than 4 of the past 7 days and at least one other positive test: (a) weakness or atrophy in the ulnar innervated intrinsic hand muscles; (b) Tinel’s sign; (c) reversed Phalen test; or (d) pressure test over the Guyon’s canal
Carpal tunnel syndrome: pain or paraesthesia or sensory
Carpal tunnel syndrome: intermittent paraesthesia or pain in at least two
loss in the median nerve distribution and other positive
of the ﬁ rst three digits, which might also be present at night (producing
test: (a) Tinel’s test; (b) Phalen’s test; (c) nocturnal
pain in the palm, wrist, or radiation proximal to the wrist) for more than
pain at night, paraesthesia in a peripheral
exacerbation of symptoms; (d) motor loss with wasting
4 of the past 7 days and at least one other positive test: (a) ﬂ exion
of abductor pollicis brevis; or (e) abnormal nerve
compression test (b) carpal compression test (c) Tinel’s sign; (d) Phalen’s
related to a peripheral nerve at the wrist
sign; (e) 2 point discrimination test; or (f) resisted thumb abduction or motor loss with wasting of abductor pollicis brevis
Non-speciﬁ c Non-speciﬁ c diﬀ use forearm pain: pain in the forearm in
Non-speciﬁ c upper extremity musculoskeletal disorders: Diagnosis by
the absence of a speciﬁ c diagnosis (sometimes includes:
loss of function, weakness, cramp, muscle tenderness, allodynia, or slowing of ﬁ ne movements)
Table 1: Suggested classiﬁ cations for RSI2
these outcomes, no signiﬁ cant diﬀ erences were seen and local corticosteroid injections provide short-term pain between treatments, so no speciﬁ c treatment strategy can relief (up to 12 weeks).73,74 Many other non-surgical be recommended to improve duration of sick leave.59,67,72
treatment options could provide pain relief. Carpal bone mobilisation, 7-weeks of ultrasound treatment, and yoga
Carpal tunnel syndrome
have shown some beneﬁ t, but small trials only were
Most patients with carpal tunnel syndrome are treated done.73,75,76 Diuretic drugs, non-steroidal anti-inﬂ ammatory with non-surgical interventions (table 2). A hand brace drugs (NSAIDs), vitamin B6, magnet therapy, laser improves symptoms, and 2-week oral steroid treatment acupuncture, use of ergonomic keyboards, exercise, and
www.thelancet.comVol 369 May 26, 2007
Surgical treatment relieves symptoms better than splint-
ing.94 However, two small trials only have compared surgery
with splinting in patients with severe carpal tunnel symp-
Local corticosteroid injections (short-term)
toms. Whether this result applies to patients with mild
symptoms is unknown. Two studies comparing surgery
with steroid injections showed conﬂ icting results.95,96 None
Endoscopic carpal tunnel release versus open carpal tunnel release 12
of these studies included exclusively a working population. Cubital tunnel syndrome
Local corticosteroid injections (long-term)
Treatment of cubital tunnel syndrome is generally conser-
vative for at least 6 months.97 Such treatment aims for
return to functional strength and mobility of the aﬀ ected
arm, and consists of manual therapy, splinting, stretching
exercises, and pain management. Surgery might be neces-
sary if conservative therapies fail, although optimum
surgi cal management is controversial. Of the surgical inter-
ventions, medial epicondylectomy provides the best symp-
tom relief for patients with mild symptoms, and anterior
Internal neurolysis in conjunction with open carpal tunnel release
subcutaneous transposition provides the least relief.98
Wrist splints after carpal tunnel release surgery
Submuscular transposition is most eﬀ ective for patients
with moderate symptoms. For patients with severe cubital
Table 2: Common interventions for carpal tunnel syndrome.5
tunnel syndrome, the best treatment option is unknown.98 None of these studies included exclusively a working
Intervention of trials
Topical non-steroidal anti-inﬂ ammatory drugs (short-term)
Lateral epicondylitis (tennis elbow)
Oral non-steroidal anti-inﬂ ammatory drugs (short-term)
Most patients with lateral epicondylitis are treated
conservatively in primary care (table 3). Oral and topical NSAIDs provide short-term pain relief in patients with this
disorder.99 Only one trial evaluating these drugs included
Percutaneous tenotomy or formal open release
reduction of sick leave as an outcome and noted no beneﬁ t
over placebo.100 Corticosteroid injections are eﬀ ective for
Non-steroidal anti-inﬂ ammatory drugs (long-term)
short-term (6 weeks or less) pain relief, increase of grip
strength, and overall improvement, but do not provide
intermediate or long-term eﬀ ects.101 Ultrasound can also
reduce symptoms.102 Other treatment options for lateral
Table 3: Common interventions for lateral epicondylitis6
epicondylitis are acupuncture (either needle or laser), orthotic devices, lasertherapy, electrotherapy, exercises,
chiropractic care have not yet shown symptomatic beneﬁ t and mobilisation techniques, but the eﬀ ectiveness of these when in controlled trials.73,75,76 No trials about carpal tunnel
therapies is unknown.103,104 Shockwave therapy is not useful
syndrome have included exclusively a working population
for lateral epicondylitis.102,105 Surgery is also a treatment
option in patients with severe symptoms. Percutaneous
Endoscopic and open carpal tunnel release are surgical tenotomy for lateral epicondylitis seems somewhat better
treatment options that can improve symptom relief in than open tenotomy for improvement of disability and patients with severe electromyograph-conﬁ rmed carpal decreasing recovery time and return-to-work.106,107 None of tunnel syndrome.77–91 No alternative to standard open carpal
the studies exclusively included a working population.
tunnel release (a new modiﬁ ed incision; epineurotomy; internal neurolysis [epineurotomy then division of the Neck pain nerve resulting in nerve decompression]; tenosynovectomy
Patients with neck pain are usually treated in primary care
[excision or resection of a tendon sheath]; Knifelight with non-surgical interventions (table 4). Exercise therapy instrument [a knife with integrated light source]) seems to
has some short-term beneﬁ t on pain and function for
oﬀ er better relief from symptoms in either the short-term patients with neck pain.108–115 Seven trials of exercise for or the long-term.92 Neural surgery (neurolysis or neck pain have included exclusively a working population. epineurotomy) could even be harmful for patients with No type of exercise (eg, strengthening, stretching, carpal tunnel syndrome.93 Complications are frequent with
surgery, but no severe complications resulting in permanent
recommended over others. Diﬀ erences in eﬀ ect, if any,
damage or serious impairments have been described.91,92
across types of exercise are small. Manipulation and
www.thelancet.comVol 369 May 26, 2007 Intervention Intervention of trials of trials
Intra-articular corticosteroid injections
Physiotherapy (manual treatment, exercise)
Arthroscopic laser subacromial decompression
Manipulation under anaesthesia plus intra-articular injection in
Intra-articular non-steroidal anti-inﬂ ammatory drugs
Multidisciplinary biopsychosocial rehabilitation
Oral non-steroidal anti-inﬂ ammatory drugs
Table 4: Common interventions for neck pain.7
Topical non-steroidal anti-inﬂ ammatory drugs
mobilisation are not useful on their own for mechanical
neck disorders with or without headache.116 However,
Table 5: Common interventions for shoulder pain8
mobilisations or manipulations combined with exercises might be useful for pain reduction, improvement in function, and reduction of amount of sick leave.
in func tion.123 Ultrasound and pulsed electromagnetic ﬁ eld
Intra-muscular injection of lidocaine could be an eﬀ ective ther apy are possible treatments for shoulder pain, adhesive
treatment for some patients with chronic neck pain.117,118
capsulitis, or rotator cuﬀ tendonitis but their beneﬁ ts are
Epidural injection of methylprednisolone with lidocaine unproven. might be helpful for reduction of sick leave after 6 and
If one intervention has not been beneﬁ cial, multi-
12 months for patients with chronic neck pain with disciplinary programmes are a sensible treatment option radicular ﬁ ndings. For patients with cervicobrachial pain, for workers with shoulder pain.124 The content of these radiofrequency denervation might provide short-term pain
programmes can vary, and also the disciplines involved:
relief.119 Other commonly used treatment options for neck physicians, physical and occupational therapists, and pain are a collar, NSAIDs, psychotropic medication, psychologists might all have a role. Whether psychologists electrotherapy, and transcutaneous electrical nerve should provide behavioural treatment or merely advise the stimulation. Whether these interventions are eﬀ ective or rehabilitation team has not been well established.125 Also, if not is still unclear.117,120
regular interventions have not been beneﬁ cial, some patients with shoulder pain might want to try alternative
Corticosteroid injections are commonly used for treatment
treatments, such as acupuncture, has not been proven.126
of shoulder pain (table 5).121 Little evidence is available to
Patients with resistant or longstanding shoulder pain are
guide treatment as to the number, site, and dose of often referred for specialist treatment, such as surgery. injections. Subacromial corticosteroid injection for rotator
Arthroscopic decompression is probably bene
cuﬀ disease and intra-articular injection for adhesive rotator cuﬀ ,8 although a randomised trial did not ﬁ nd a capsulitis could be beneﬁ cial although their eﬀ ect might diﬀ erence compared with conservative treatment.127 None be small and not well-maintained.121 Steroid injection of these studies exclusively included a working population. might somewhat speed up return-to-work, as seen at 12 months follow-up in one study.122 Physiotherapeutic Conclusion interventions are also widely used for treatment of shoulder
No consensus exists on use of the term repetitive strain
pain. Exer cises, either alone or combined with mobilisation,
injury (or any other term), and little is known about the
pro vide short-term recovery and long-term improvement pathophysiology of this disorder. Evidence about risk factors
www.thelancet.comVol 369 May 26, 2007
is increasing but the relative eﬀ ects of such risk factors are
Ashworth N. Carpal tunnel syndrome. Clin Evid 2005; 14: 1351–65.
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27 Roquelaure Y, Mariel J, Fanello S, et al. Active epidemiological
Conﬂ ict of interest statement
surveillance of musculoskeletal disorders in a shoe factory.
We declare that we have no conﬂ ict of interest
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