Repetitive Strain Injury

Written by Marek Kolarik

Repetitive strain injury (RSI) is a term used to characterise pain in the upper extremity. It involves pain in the neck, shoulder, elbow, forearm and wrist. It predominantly includes injuries caused by repetitive movements or overuse, hence the name repetitive. Common movements causing this type of strain injury include; using a computer mouse or keyboard, using vibrational tools such as power drills, mechanical compression, heavy lifting, poor posture or poor working position set-up.

RSI has a poor description for the actual cause of the injury to the upper limb, and therefore other terms are used such as “non-specific work- related upper limb disorder”, “occupational overuse syndrome” or “repetitive strain disorder”. RSI is more of an umbrella term encompassing more specific diagnoses that are related to certain areas of the body or certain soft tissues within the body. For example:

Tendon Related Disorders

Tendonitis and tenosynovitis (inflammation of tendons) usually present with swelling, redness and heat around the tendons. This type of injury is common in the shoulder, elbow and forearm. Specific examples are shown below:

• De Quervain’s tenosynovitis – irritation and inflammation of the tendons around the thumb.
• Epicondylitis known as Golfer or Tennis elbow – irritation and inflammation of the tendons around either side of the elbow.
• Rotator Cuff tendonitis – irritation and inflammation of the tendons in the shoulder.Pain is usually felt in overhead activities.

Peripheral Nerve Entrapment

• Carpal tunnel syndrome – symptoms usually include pain with pins and needles or numbness in the palm and the thumb plus 2nd and 3rd finger, followed by weakness and difficulty gripping. Generally worse at night.
• Cubital tunnel syndrome – similar to carpal tunnel syndrome, however the ulnar nerve at the affecting ulnar nerve cubital tunnel at elbow is affected.
• Guyon tunnel syndrome – compression of ulnar nerve in Guyons canal located at the wrist, commonly causing numbness below the wrist and in 4th and 5th finger.

Typical signs and symptoms in RSI:

Sharp or shooting pain, aches and tenderness in or around the joints of the neck, shoulder, elbow or wrist. You might also experience:

• Stiffness
• Numbness
• Tingling (Pins and Needles)
• Cramp
• Weakness, inability to grip
• Swelling
• Sensitivity to cold or heat
• Loss of sensation

Symptoms typically start gradually and worsen over time, with increasing repetition, but also may be worsened by extreme load or activity after work (example playing tennis or other activities which may over strain problematic areas).

In common RSI presentations symptoms usually get better during the days off from work, or during holidays where the routine of overuse has been changed. This will naturally allow the overworked tissues to heal.

At the initial start the symptoms are worse only when specific strenuous activity is taking place, affecting usually one area of upper extremity. However, over time the intensity of symptoms may increase and cause pain and discomfort in other parts of the upper extremity. This can create chain reactions and further dysfunction due to poor biomechanics and may cause pain in the neck. Without treatment, duration of pain may persist over months, with failing to recover during the time off from occupational repetitive strain. Symptoms can start to include behavioural changes such as:

• Avoiding using injured hand/arm
• Using non-dominant hand more often
• Changing the style of clothes, may be too difficult to put it on
• Not participating in sports or activities, which may increase the discomfort
• Being exceedingly protective of your hands
• Having trouble brushing teeth, chopping food, using keyboard or typing on phone.

The main cause of RSI is overuse in different parts of the upper extremity. This includes specifically, muscles, tendons, ligaments and nerves in the upper body. It is generally caused by mechanical overuse, but other risk factors like poor sleep, increased stress and poor posture are important to include when diagnosing RSI. The mechanical causes can be:

• Heavy lifting
• Prolonged period in the same position (sitting behind the desk)
• Lack of exercise (musculoskeletal system fails to compensate with loads)
• Overuse of specific joints and tissues around them to an excessive degree

Jobs where RSI can develop over time are physically demanding jobs or jobs where awkward position or posture is maintained for a longer period of time. Usually high demand, not taking enough breaks, or having poor technique are the maintaining factors. Predisposing factors in some patients with RSI are other underlying medical conditions such as arthritis, or joint hypermobility syndrome.

It is commonly seen not only in desk based jobs, but also with construction workers, cleaners, musicians, manual therapists, bus drivers and dental hygienists.

Your local GP, physiotherapist or osteopath can diagnose repetitive strain injury. Your initial consultation will consist of a thorough case history taking along with a postural and physical examination. Basic physical tests are performed where the musculoskeletal system and nerves are examined by performing certain movements. The aim of the physical assessment is to provoke or relieve the symptoms by doing special tests.

Your healthcare professional will ask a series of questions to help understand the underlying cause of your symptoms. They will also ask about your medical history including medical diagnosis. This is necessary to include or exclude other underlying conditions such as diabetes or autoimmune inflammatory disease.

In the case of symptoms being severe or a patient is not progressing with conservative treatment then the standard option for diagnosing the problematic area is through medical imaging (MRI, X-Ray, Ultrasound). This is used to assess the damage to the tissues. Electromyography will assess the function of the muscles and nerve conduction studies will test the nerve functions.

The first line of treatment is rest and reducing the repetitive activity which is causing the strain injury. At times this might be not possible since the certain activity is part of the job. In this case, discussion with your employer to adjust your working station, or work load for some period of time will be advisable, until full recovery.
Other treatment options include:

• Physical Therapy (Physiotherapy, Osteopathy) – to improve body tissues by strengthening them and improving range of motion.
• Medication (Non-steroidal anti-inflammatory drugs) – to help reduce inflammation and pain.
• Corticosteroid injection (should not be taken for long periods)- used to help reduce inflammation and to help with pain levels.
• Braces – this may help the body to allow the healing process and act as a support.

The main goal in these treatment options are to restore correct biomechanics of the upper extremity and reduce pain, as well as preventing further episodes of RSI.

If conservative treatment options are unsuccessful and pain with dysfunction prevail then the last option is surgery. Surgery is performed usually with severe cases and as a last resort treatment option.

The longevity of RSI is the same as in any of the strain injuries, and it is very individual case by case. Mostly it is depending on what tissues are damaged. Muscles in normal healthy individuals usually heal faster than tendons or ligaments. Healing time is also dependant on the below factors:

• Other important factors are:
• Chronic or long term recurrent injury
• Underlying medical condition
• The severity of the damage in the tissues
• Poor coping mechanisms (lack of sleep, increased stress)
• General health (obesity, fitness level)

One of the best prevention to any disease, or syndrome is to stay active and exercise on a regular basis. If the RSI is caused by doing too much or too little at your workplace then the best prevention is taking breaks from inactivity or strenuous activities.

This may include:

• Getting up and stretching your shoulders, arms and wrists
• Adjusting the work station (sitting to standing desk
• Promoting good posture (prevent slouching, or sitting crossed legged)
• Employer should provide the right equipment for your job
• If you are stressed, try breathing exercise or other alternative stress relief techniques
• Improve your sleeping habits if you don’t feel rested when waking up in the morning.

The best exercises for RSI are aimed at strengthening and stretching the affected area.
The aim of the exercises are to reverse and prevent further damage to the affected tissues.

Common exercises for RSI include:

Wall Stretch- Extend your arm behind you, using the wall as support. Stretch out your shoulder, arm and wrist all at the same time. Hold this position for up to 1 minute. You can try to move your arm to different angles to include all muscles which may be involved within the problematic area.

Chest stretch- Begin by standing in a door frame. With your injured side, bend your elbow to 90 degrees and rest your forearm and hand on the door frame. Your feet should be in a plit stand position, hips facing forward. Push your chest slightly forward and bend your knees. You should feel a scratch through the front of your chest. To increase the stretch rotate your trunk to the opposite side. Hold for 20 seconds and repeat 5 times.

Forearm Stretch- Place your palms onto the desk or floor with your fingers facing towards you. Try to maintain the palms down, if needed bend your elbows, making sure to remain relaxed in your shoulders keeping them down away from your ears. Lean backwards towards your heels to increase the stretch into your forearms. Holding up to 1 minute. Repeat 5 times.