#24 – Treating repetitive stress injuries

Carpal Tunnel Syndrome can stop your career. In some cases it can start almost immediately with no warning. It can start with pain in your fingers that later radiates up to your elbow.

The median nerve travels from the forearm into your hand through a “tunnel” in your wrist. The bottom and sides of this tunnel are formed by wrist bones and the top of the tunnel is covered by a strong band of connective tissue called a ligament. This tunnel also contains nine tendons that connect muscles to bones and bend your fingers and thumb. These tendons are covered with a lubricating membrane called synovium which may enlarge and swell under some circumstances. If the swelling is sufficient it may cause the median nerve to be pressed against this strong ligament which causes carpel tunnel.

Mild cases may be treated by applying a brace or splint which is usually worn at night and keeps your wrist from bending. Resting your wrist allows the swollen and inflamed synovial membranes to shrink; this relieves the pressure on the nerve. These swollen membranes also may be reduced in size by medications taken by mouth called non-steroidal anti-inflammatories. In more severe cases, your doctor may advise a cortisone injection into the carpal tunnel. This medicine spreads around the swollen synovial membranes surrounding the tendons and shrinks them, and, in turn, relieves the pressure on the median nerve. The dosage of cortisone is small and when used in this manner it usually has no harmful side effects. The effectiveness of non-surgical treatment is often dependent on early diagnosis and treatment.

In those patients who do not gain relief from these non-surgical measures it may be necessary to perform surgery. The site of the operation is made pain-free by local anesthesia injected either into the wrist and hand or higher up in the arm. This may be done by your orthopedic surgeon or an anesthesia doctor. The surgery itself is called a “release” – cutting the ligament that forms the roof of the carpal tunnel to relieve the pressure on the median nerve. The surgery is usually performed in an outpatient facility and you are generally not required to stay overnight.

Your doctor can explain to you the likelihood of non-surgical or surgical treatment based on your own individual circumstances.


1. Wrist pain radiating up the arm to the shoulder
2. Swelling and tenderness in forearm
3. Numbness, burning and tingling in thumb, index, and long finger that can be reproduced by bending the wrist down for one minute
4. Clumsiness, weakness
5. Hand pain at night
6. Morning stiffness
7. Decreased range of motion
8. Deformity
9. Cramping
10. Difficult to make a fist
If you notice any of these symptoms, tell Patty or Dr Smith immediately. Do not ignore these
symptoms. Early intervention may avoid surgery.

Risk factors in dentistry (for most cases, there is no known cause)

1. Poor positioning or same posture for long periods of time
2. Mechanical stress from small diameter instruments
3. Tug-back from cords
4. Ill fitting gloves
5. Repetitive movements of hands or wrist for long periods of time without breaks
6. Arthritis, Diabetes
7. Thyroid gland imbalance
8. Using fingers rather than hands
9. Menopause or other hormonal imbalances
10. Pregnancy
11. Dull instruments
12. Vibration from ultrasonics while using tight grasp and poor wrist position

Reduce the risks (See #3 in this level)

A. Reduce grip force
1. Use large handled instruments to reduce grip pressure
2. Practice a light grip
3. Keep instruments sharp
4. Use proper fitting gloves
5. Polish selectively

B. Change body position often to reduce fatigue
1. Periodic stretching exercises
2. Don’t schedule an STM for longer than an hour

C. Alternate vibrating and hand instruments to reduce vibration in hands
1. Use ultrasonics as much as possible
2. Hand instruments design
a. Wide diameter, hollow textured handles
b. Pick a weight that feels right to you

D. Properly fitting gloves are very important
1. Avoid tight fit at wrist and fingers
2. Don’t wear expandable wristband watches

E. Proper instrumentation
1. Limit wrist and finger motions

These are the standard concerns noted in hygiene. Can you think of any other risks?

Types of musculoskeletal disorders

A. Cervical Myofascial Pain Syndrome
1. Symptoms
a. Neck pain and stiffness
b. referred pain and sensory disturbances
2. Treatment Recommendations
a. Ergonomic changes
b. Analgesic medications
c. Modalities for the relief of muscle tightness
d. Physical therapy with an emphasis on stretching

B. Rotator Cuff Tendonitis (caused by working with elbow too high)
1. Symptoms
a. Shoulder pain especially with overhead activities
b. A feeling of shoulder weakness secondary to pain
c. Interference with sleep secondary to pain
d. Cracking sounds in shoulder when arm moved
2. Treatment Recommendations
a. Anti-inflammatory medication, rest, strengthening
b. Modification of activities to specifically avoid shoulder internal rotation and excessive overhead reaching
c. Subacromial steroid injection

C. Lateral Epicondylitis (tennis elbow) muscles that pull wrist upward
a. Pain over the lateral epicondyle region especially when you make a fist, turn forarms down, when elbows are straight
2. Treatment Recommendations
a. Tennis elbow counterforce brace
b. Wrist splints
c. NSAIDS, ice, rest,
d. Corticosteroid injection into lateral epicondyle region
e. Physical therapy for pain-relieving modalities and wrist extensor strengthening
3. Prevention- exercise program to strengthen muscles

D. Medial Epicondylities (golfers elbow)- muscles that pull wrist downward
1. Symptoms
a. Pain over medial epicondyle region especially during activities
2. Treatment Recommendations
a. Tennis elbow counterforce brace worn over medial epicondyle region
b. Wrist splints
c. NSAIDS, ice, rest, avoid movements that increase pain
d. Corticosteroid injection into lateral epicondyle region
e. Physical therapy for pain-relieving modalities and wrist flexor strengthening
3. Prevention- exercise program to strengthen muscles

E. De Quervain’s Tenosynovitis (caused by repetitive use of thumb
1. Symptoms
a. Aching discomfort along the base of the thumb (worse with ulnar deviation of the wrist)
b. Occasional pain migration into forearm
2. Treatment Recommendations
a. Eliminate wrist ulnar deviation
b. Temporary use of thumb splint (6 weeks)
c. Corticosteroid tablets or injection
d. Surgical release of tendon sheath (refractory or recurrent cases)

F. Carpal Tunnel Syndrome
1. Symptoms
a. Pain tingling, numbless
b. Finger/hand incoordination
c. Rapid onset hand fatigue
d. True hand weakness (severe cases only)
e. Nocturnal symptom exacerbation
f. Positive flick sign
2. Treatment Recommendations
a. Ergonomic modification (change your technique)
b. Wrist splint
c. Analgesic medication
d. Vitamin B6
e. Corticosteroid tablets or injection
f. Carpal ligament release surgery (refractory or recurrent cases)

G. Cubital Tunnel Syndrome
1. Effects that ulnar nerve where it crosses the elbow (funny bone)
2. Symptoms
a. numbness or weakness in little finger or forth finger
3. Treatement
a. Elbow pad during the day
b. elbow spling (limit to 45% angel of motion ) to wear at night
c. Surgery as a last resort

H. Arthritis
1. Usually begins in middle age or older
2. Repetitive actions make it worse
I. Lupus
J. Gout

Conservative Treatments

1. Temporary work applications
a. Rest allows the swollen and inflamed synovial membranes to shrink, relieving pressure on the nerve
b. Exercises
c. Aspirin or ibuprofen to reduce inflammation

2. Professional help – reversible
a. Refer to a healthcare professional
1. Evaluation – we will provide any needed information
a. description of your tasks and potential repetitive stress hazards
b. available work restrictions
c. a copy of the OSHA proposed standard
d. offer for health care professional to perform work place walk through
2. Management
3. Follow up
4. Written opinion to you and a copy to HealthPark
a. opinion about medical condition related to your injury and what job hazards might have
caused it
b. any health condition not related to injury should not be included in the report
c. any temporary work restrictions
d. any other physical activities that could aggravate this injury
b. Hand/wrist brace to wear all the time or at night
c. Cortisone injections (quick improvement, short duration)
d. Physical therapy – ultrasound, cold packs, electrical stimulation

3. Usually an OSHA reportable incident if
a. lasts 7+ consecutive days
b. lost 1+day of work
c. cannot do all work functions

Work restriction continues until
1. You are cleared to return to full time duties
2. Your job is modified to eliminate the injury producing situations
3. 6 months have passed
4. Pay during this period will be determined

1. Usually done on an outpatient basis
2. Local anesthesia
3. Cut ligament that forms roof over carpal tunnel to relieve pressure on median nerve
4. Expect 6 8 weeks before you could return to work

You currently
1. Understand that repetitive stress injury risks
2. Have reviewed with team leader recommended approach to avoid these injuries
3. Have discussed any ideas to reduce these potential injuries

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Teamleader                                              date