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Published: 2008-03-26

Repetitive Trauma



In Illinois, repetitive trauma cases are compensable, as a general rule, accidental injuries under the Workers' Compensation Act. As a result, in a repetitive trauma case, it is necessary, as it is for any other accidental injury, for the Petitioner to establish a date of accident. Petitioner must also provide notice as required by Section 6(c) of the Illinois Workers' Compensation Act and the claim must be filed within the time restraints provided by Section 6(c) of the Illinois Workers' Compensation Act.

A number of terms, including repetitive stress injury have been introduced using the works repetitive, cumulative, motion, strain, overuse, trauma, injury and/or disorders refer to a collective variety of painful, chronic neuromusculoskeletal disorders of the neck, hand and arm. These upper extremity disorders can be caused by repetitive movements, occupational or otherwise. The occurrence of neuromusculoskeletal disorder depends on three factors: the amount of tissue damage (relating to repetition, force, duration of exposure, position and vibration,) individual parameters (e.g., age, systemic illness, obesity, and physical fitness), and psychosocial factors (especially individual balances between stress and coping mechanism between home and work).

ACCIDENT

Prior to 1987, proving a date of an accidental injury in the repetitive trauma case was very difficult. The general rule is that an employee seeking benefits for gradual injury due to repetitive trauma must meet the same standard of proof as a claimant alleging a single, definable accident. It had generally been held that to establish an accidental injury, there must be proof as to time, place, and cause. That concept has been significantly broadened in recent years in the area of repetitive trauma cases. In Peoria County, Belwood Nursing Home v. Industrial Commission, 115 Ill.2d 524 (1987) a claimant had worked for the Respondent for 12 years, the last six in the laundry room. Her duties required were for her to carry bags of laundry weighing between 25 and 50 pounds. They were sorted, and she would load two, two hundred-pound capacity washing machines by operating a spring-loaded door in each of these compartments. She loaded the machine six times a day. There was no dispute regarding the causal connection between the work activity and the fact that she did have carpal tunnel syndrome. The issue was whether or not the Petitioner could establish "accident" within the meaning of the Act. The Supreme Court held that "the purpose behind the Workers' Compensation Act is best served with allowing compensation in the case like the instant one where an injury has been shown to be caused by the performance of the claimant's job and has developed gradually over a period of time, without requiring complete dysfunction . . . to deny him employee benefits for a work related injury that is not the result of a sudden mishap or completely disabling penalizes an employee who faithfully performs job duties despite bodily discomfort and damage". The Court further held that the date of an accidental injury of a repetitive trauma compensation case is that the date of which the injury "manifests itself". "Manifest itself" means that the date on which both the fact of the injury and the causal relationship of the injury to the claimant's employment would have become plainly apparent to a reasonable person. Since Belwood, there has been a long line of cases affecting the date of accident. In Oscar Meyer and Company v. Industrial Commission 176 Ill.App.3d 607 (4th Dist. 1988) the Petitioner had been diagnosed as having carpal tunnel syndrome but continued to work, without having surgery. He finally opted to have surgery but his disablement would have came after the three year Statute of Limitations had passed from the initial diagnosis. The court recognized that repetitive trauma injuries may take years to develop to the point of severity precluding the employee from performing in the workplace. The court expressed its concern that when an employee discovers the onset of symptoms and the relationship to the employment, but continues to work faithfully without significant medical complications or lost working time, they will be prejudiced of the actual breakdown and physical structures caused beyond the period of limitations set by statute. Therefore, the Court held that the date of injury was not synonymous with the date of discovery of the injury and its relationship employment but could also be the last day worked prior to the disablement or surgery.

The Appellant Court appeared to alter its Oscar Meyer position shortly thereafter, in Three "D" Discount Stores v. the Industrial Commission, 198, Ill.App.3d 43 (4th Dist. 1989) by stating that the claimant cannot always establish the date of accident in the repetitive trauma case by reference to the last day of work. The court originally denied compensation in this case since the claimant failed to establish an identifiable date in which the injury manifested itself. The evidence showed that the injury could have manifested itself anytime between January 1984 and August 1984 "last day worked". However, on the claimant's motion for rehearing, the court considered its position and found for the claimant. The Court concluded that the evidence could reasonably be interpreted to show that the injury manifested itself on the earlier date and that was good enough for the claimant to prevail.

The Court pointed out that there is no hard and fast rule regarding manifestation date of an injury. "Manifestation date" was first defined in Belwood as the date on which both the fact of the injury and causal relationship to the injury to the claimant's employment would become plainly apparent to the reasonable person. The Three "D" Discount court emphasized that the peculiar facts of each must be closely analyzed in repetitive trauma cases to be fair to the faithful employee and his employer as well as to the employer's compensation insurance carrier. Thus, the test of when an injury manifested itself in an objective one determined the facts and circumstances of each case. Although the test is objective, it may also be elusive, especially when one considers the difficulty the Industrial Commission and the Court have had in agreeing upon a correct date of accident in repetitive trauma cases.

In general, the Petitioner would appear to have two choices for when his/her injury manifested itself. The claimant could choose either of the following depending on the facts of his/her own accident. (a) The date of the discovery of the condition and its relation to the employment (as would have been plainly apparent to a reasonable person) or (b) the last day that the Petitioner worked prior to the disablement (the time that which an employee can no longer perform his job). To make matters more difficult, in the most recent case of significance, Castaneda v. Industrial Commission, 231 Ill.App.3d 734, (3d Dist. 1992), the Appellant Court denied the Petitioner's claim as last day of work as her accident date where she was unable to show that her last date was accompanied by any change in her condition or her seeking medical attention, and were the Petitioner had believed that her condition was work related and set medical attention more than two years earlier. The result of this was that the Petitioner's claim was barred by the Statute of Limitations. The choice of the last day worked as the date of accident may be rejected by the Industrial Commission unless some injury related significance can be attached to the date.

Determining what date to use for the date of accident is still a very difficult situation. There could easily be more than one date when the injury "manifested itself". These dates could be based on one or more of the following, depending on the facts of the case: 1) the date on which the symptoms became more acute at work, 2) the date on which the Petitioner first noticed the condition, 3) the date of which the Petitioner first seeks medical attention for the condition, 4) the date the Petitioner is first informed by a physician that the condition is work related, or 5) the date that the Petitioner is first unable to work as a result of the condition.

Because the date of accident in repetitive trauma cases is difficult to establish, the 45-day notice requirement, also becomes difficult to calculate. With regard to notice, in view of the nature of repetitive trauma cases, there have been cases where notice had been found to been given prior to the date of the accident. Because of the difficulty with the issue, the notice provisions of the Act have been ruled to be liberally construed in favor of the Petitioner.

CAUSAL CONDITION

In repetitive trauma cases, the Petitioner must show that the injury was work related, i.e. that the Petitioner's employment subjected him/her to a greater risk than that faced by the general public, and not the result of a normal degenerative aging process nor the result of some other non-work related condition. Causal condition is normally established or brought in by expert medical testimony. Accordingly, it is very important for the Petitioner and the Respondent to give medical experts as detailed of a history regarding repetitive physical activity as possible. The weight accorded an expert opinion must be measured by the facts supporting the opinion and the reasons given for this conclusion. It has been long agreed that sports can cause disorders of gradual onset related to repetitive motion. Similar repetitive movement and static postures can be assumed by individuals at work. The Petitioner must now prove that the disorder exists and establish causation.

TYPES OF REPETITIVE TRAUMA INJURIES

It has been recognized that any part of the body can be injured by repetitive trauma. Of the most significant are those to the upper body. Repetitive trauma injuries can be caused by repetitive movements, occupational or otherwise, and abnormal posture static position, occupational or otherwise. As generally recognized in the workplace, repetitive physical activities include the use of power tools, hand tools, vibrating tools and equipment work in a cold temperature, any work involving repeated stress or pressure of the particular part of the body or joint, virtually any assembly line work, work involving reaching over the head, repeated squeezing, repeated flexion and extension of the wrist, repeated arm movements, holding the hands in a certain position while applying any amounts of pressure or force, repetitive lifting, or working on natural conditions. Repetitive trauma injuries can be caused to the fingers, hands, wrists, elbows, shoulders, back, neck, knees, ankles and others.

The most common upper body repetitive trauma conditions are carpal tunnel syndrome, which is compression of the median nerve at the wrist, cubital tunnel syndrome, which is compression of the ulnar nerve at the elbow and thoracic outlet syndrome, which is a complex series or problems.

The first group of conditions are caused by neural entrapment of one of the upper extremities nerves at one of the several locations of the upper extremity.

Carpal Tunnel Syndrome - Carpal tunnel syndrome is characterized by numbness and tingling in the fingers, most specifically the thumb, the index finger and the long finger. It is also characterized by hand and wrist pain and lost of grip strength. Carpal tunnel syndrome will also produce symptoms in numbness and pain at night.

This symptom occurs because the nerve at the wrist, called the median nerve, is compressed in a tunnel called a carpal tunnel. Over the palm of the hand there is a strong ligament connecting the wrist bone. This creates a tunnel beneath the ligament connecting these bones. Through this tunnel runs the median nerve which contains thousands of small individual nerve fibers. Pressure on this nerve comes from the thickened amount of tissue that surrounds the tendons that moves the fingers. When the pressure builds up the blood flow in the nerve decreases. When the nerve does not get enough blood flow it does not get enough oxygen and begins to give the feelings of numbness and tingling in the fingers. When the wrist bends down, as would happen when you are asleep it further decreases the blood flow, which causes the person to wake up with his hands "asleep".

Generally, medical treatment will begin as conservative non-operative course of treatment. The goal of the treatment is to take pressure away from the median nerve. This is done by way of splinting, which keeps the wrist in a straight or neutral position attempting to take pressure off the nerve. This is especially useful at night. Often splinting is combined with medical treatment in the way of anti-inflammatory or a dose of vitamin B6. Injection of a cortisone containing solution in the carpal tunnel may also give relief, although symptoms are likely to return unless there is a change in the repetitive activities that caused the problem in the first place.

In the event of failure of the non-operative conservative treatment, the next type of treatment would be surgical decompression. There are two schools of thought regarding surgery for relief of the carpal tunnel condition. The most widely used is an open operation whereby an incision is made at the base of the palm of the hand and the carpal ligament is cut which releases the pressure on the nerve. The second type of surgery is an arthoscopic procedure whereby small incisions are made and an arthoscopic device is inserted in the hand and microsurgery is performed. This procedure is now considered controversial for primary carpal tunnel release but is an essential technique for a second time carpal tunnel release to eliminate scar tissue which builds inside the nerve.

The recovery phase generally involves physical therapy to help the hand regain its softness, movement and strength, but usually exercises can be taught to do at home. The numbness and tingling should be greatly diminished shortly after the surgery. Occasionally, symptoms due to scarring inside the nerve from actual loss or degeneration of nerve fibers can occur. It may take six months to a year for muscle strength and the ability to discriminate in the tips of the fingers to completely recover.

Other symptoms in the hand can involve compression of the nerves at the ulnar tunnel at the wrist, which is also called the Guyon's canal, or the radial nerve. Similar types of treatment and recovery can be expected for these conditions.

Cubital Tunnel Syndrome - Cubital tunnel syndrome is another condition that is growing in popularity. Again these are caused by neural entrapment based on some repetitive action or traumatic action. These problems are due to pressure on the nerve, the ulnar nerve, in the bony tunnel at the elbow called a cubital tunnel. This is an area where a bump to the elbow give a tingling in the little and ring fingers, in which people say, "they have hit their funny bone." The group of problems include numbness or tingling in the little and ring fingers, clumsiness, and weakness of the grip or pinch.

The cubital tunnel has bone on either side and a bony groove at the base with a ligament causing the nerve from the top of one bone to the other. The ulnar nerve, which is the size of a pencil, controls the muscles for grip strength, primarily in the little, ring and often the middle finger. It controls the muscles for most of the pinch strength and controls the muscles of the hand to coordinate fine movements of the hand, with the exception of muscles that lift the thumb up and out and from the palm and turn the thumb for pinching.

Again, non-operative conservative treatment is the first step in treating this condition. The main non-operative method for relieving pressure on the ulnar nerve at the elbow is to keep the elbow as straight as much as possible. Regular daily activities must be altered. Splinting to keep the elbow straight or slightly flexed is often used. Again, anti-inflammatory medication is also used as well as certain types of physical therapy.

There are several operative approaches to the treatment to decompression at the ulnar nerve at the elbow. The most frequent is described often as an operation that moves the nerve from its location behind the elbow to a location in front of the elbow. This called an anterior submusclar transposition of the ulnar nerve. This involves an incision behind the elbow. After surgery there is a period of immobilization followed by less splinting. Exercise in the way of physical therapy will also be added within several weeks after surgery.

The second group of upper extremity constricted states that can be related to repetitive trauma are those relating to Stenosing tenosynovitis, and inflammation and narrowing of the tendon sheath. These include trigger finger, De Quervain's syndrome, Extensor pollicis longus, Tendonitis, and Tenosynovitis.

THORACIC OUTLET SYNDROME

A growing diagnosis for subjective pain and numbness in the upper extremities is that of a thoracic outlet syndrome. TOS usually complains of sensory disturbances in their arm, forearm or hand especially with the use of extremities and overhead activities. Patients may describe pain and aching in the shoulder region and numbness or "pins and needles" in his arm and hand when they use their arms above their head. Persons with this condition frequently describe tension headaches in the center of the back of their neck or base of the skull. Occasionally, TOS suffers describe face and anterior chest wall pain.

The nerves that supply the muscles and skin in the upper extremity leave the spinal cord in a complicated organization of nerve fibers, roots and bundles which is termed the brachial plexus. In the neck the brachial plexus lies between two small, tight, fibrous-like muscles which are called the anterior and middle scalene muscles. These muscles attach to the first rib in the front of the chest, and the transverse processes at the cervical vertebrae at the side of the neck. These muscles, especially when they become tight, compress the brachial plexus in the region of the neck. This compression is termed thoracic outlet syndrome.

A job which requires continuous overhead actions may cause symptoms related brachial plexus compression within a short period of time. A person who maintains his upper extremities in a less elevated position (e.g. truck drive, computer operator) may take longer even years to develop symptoms. The cause of thoracic outlet syndrome is frequently multifactorial and may be influenced by trauma, repetitive job activities, anatomical predisposing factors and various other factors.

Patients with TOS often describe complaints similar to those with carpal and cubital tunnel syndrome. A patient with TOS is more susceptible to developing cubital and carpal tunnel and visa versa. This is susceptibility has been termed double crush syndrome.

Conservative treatment is recommended for TOS. Physical therapy is frequently useful as well as modification of job activities. Patients with TOS tend to have sloped shoulders with forward flexion of the neck and head. These problems can be addresses with therapy. Anti-inflammatories and trigger point injections may be helpful to help relieve tight muscles.

Surgery to release the nerves in the region of the thoracic outlet is difficult. It may involve the removal of the cervical rib or by decompression of the first rib resection with an incision through the armpit. Obviously, these are serious surgeries and will be used as a last resort. TOS is being recognized with greater frequencies especially with the increase in jobs that require repetitive or overhead activity and computer data entry. While surgery carries a significant risk and potential about three of four patients that have the surgery have good relief of their symptoms.

OTHER CONDITIONS

Reflex sympathetic dystrophy can be caused by repetitive trauma or basic procedures employed to correct them and can affect either upper or lower extremities.

The feet can also be affected. Tarsal tunnel syndrome and a condition similar to carpal tunnel syndrome but involving feet, as one example. Fascitias can be work related under some circumstances. Other cases, including back, neck and knee injuries especially involving recurrent herniated disc or cartilage tears in the knees can also be caused by repetitive trauma.