MSD treatment & recovery

This essay merges prevention strategies with clinic treatment approaches. Our MSD prevention tactics offer principles for more effective clinical treatment.

MSD is a Cumulative Trauma Disorder… microtrauma accumulates gradually over time, with no symptoms until the sufferer reaches a ‘critical mass’ of damage.  Symptoms arise late, in the ‘end-stage’ of their disease process.

When the injured worker arrives in the PT clinic with one MSD problem, it is usually only one hint of a larger underlying disease process, the first noticeable sign of a “complex of MSDs”.

A tennis elbow, or golfer’s elbow, or deQuervain’s, or rotator cuff impingement, or plantar fasciitis, or one of several neurovascular entrapments such as CTS… BUT any one of these is the result of a wider accumulation of microtraumas, degenerations, and dysfunctions.

We can provide Our PT interventions for the presenting symptoms, and we will likely see success… but how many will later suffer recurrences, plus develop a series of other MSD complaints?  Most will.

We too often treat the presenting complaint rather than address the underlying collection of MSD risk factors and dysfunctions.  Addressing the full scope of MSD risk factors bring better, faster, more longterm success.

I try to assume the presenting epicondyalgia, tendinitis, tendinosis, or CTS is the result of a “cascade of dysfunctions” starting with sustained sitting, forward head posture, a degree of thoracic outlet compression, secondary double crush effects (e.g., TOC leads to pronator entrapment leads to CTS).  There has been ongong degenerative changes predisposing the MSD complaint.  The tendinitis is likely, by now, actually tendinosis (degeneration vs inflammation, which changes PT Rx strategies).

I find this a useful assumption (primary sx arise from a collection of MSD-degenrative changes) when we develop our clinic treatment plan of care.  While we treat the primary site, we EDUCATE the patient on what likely led to sx, and how to correct it all, to maximize recovery and avoid recurrences, thus avoiding a lifetime of issues.

Round shoulders slouching forward head posture stresses nerves and blood supply to the working arms, allowing distal UE tissues to become inflamed from inadequate removal of working tissue metabolic waste products.  Stressful neck posture proximally can lead to distal arm-hand problems.  “So hassle yourself to sit up straight, switch between sit-stand, do frequent micro stretches in chin-tuck and at lateral neck, strengthen scap retractors.”

Check for Adverse Neural Tension signs, implying peripheral nerve entrapments or hypomobilities that may be contributing to medial epicondylalgia (ulnar… VERY common), lateral epicodyalgia (radial tunnel sx), deQuervains (musculocutaneous nv input), just as you would check for CTS sx.  Check for pronator compression of median nv as a contributor to CTS sx  (Kamath & Stothard Score best for implying symptomatic CTS).

Consider this: Simply ask each patient presenting with an UE overuse problem, “does your neck bother you?” (runs about 90%).

MY POINT… always consider PROXIMAL dysfunctions as a potential contributory issue for distal sx.  Proximal static posture stressors are a major risk for distal overuse problems.  This is a primary basis of our MSD School PREVENTION program, which serves us well in our clinic treatment work.

No, this does not overgrow treatment of a MSD complaint to make it unnecessarily bigger than it needs to be.  It does not add costly extra PT visits.  It is part of your care of the patient to address why they have a problem.  Adding some manual therapy and stretches and stability-strength home exercises is not a big add-on, especially when it prevents future recurrences and stops those other subsequent MSD complaints that will appear soon.

I mentioned plantar fasciitis, which another great example of this… especially if sx are bilateral.  Picture this cascade of dysfunctions… degenrated disc for sitting and bending exposures, distorts iliolumbar ligament support of SIJ, leads to tight piriformis.  The tight piriformis, or any disc HNP, irritates sciatic nerve proximally.  This risks secondary entrapment  (double crush) at tarsal tunnel.  A mild degree of TT compression can cause pain at medial distal calcaneous/medial prox plantar fascia.

How much of the plantar fasciitis sx is actually some degree of tarsal tunnel sx? And how much of that is caused by some degree of sciatic irritation from LB and-or piriformis.  We usually include LB-LS-SIJ stretches to address these potential risks when treating for PF… especially if sx are bilateral.

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Check this out… a summary of MSD treatment protocol used by my students
NormalizeFunctionMSD

Here is a link to powerpoint of the course I teach on this
UQ-MSD-Rx

Neck-Arm MSD self-care eBook Neck-Arm

 

CRITICAL ARTICLES LINKS!!

Excellent on eccentric exercises for tendinopathy:
https://academic.oup.com/rheumatology/article-lookup/doi/10.1093/rheumatology/ken337

Managing LB Pain Risks (2) :
The Next Path for Pain Neuroscience Education

http://www.scottgraypt.com/book-review-world-hurt/

Critical factors re Subacromial Impingement Sx (posture, etc)
http://www.sciencedirect.com/science/article/pii/S2468781216308347

Non-surgery Rx for Rotator Cuff Tears:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4827371/

To purchase self-study The Injured Worker (APTA Ortho Section)
http://orthoptlearn.org/doi/book/10.17832/isc.2014.24.1

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