Put your shoulder to the wheel.
Aesop
In the 2022-2023 reporting period, the largest proportion of serious claims by body location arose from injuries occurring to the upper limbs, at 32.6% (Safe Work Australia (SWA), 2024). Work-related upper-limb discomfort that affects one or a combination of the hands, the forearms, arms, and or the shoulders, is unfortunately common. Approximately 20% of the population will complain of pain in the upper limbs, and of this the discomfort will most commonly occur in the shoulder (Shanahan, 2006). Work-related upper limb disorders are expensive as well as being ubiquitous, where the median time lost is reported as 7.4 weeks and the median compensation paid is more than AUD$16,000 for the same reporting period (SWA, 2024). When considering all-population statistics, disorders of the upper limbs such as fractures, dislocations, soft-tissue strains and wounds are among the highest represented injuries among the assessed population (Australian Institute of Health and Welfare (AIHW), 2024), however, these statistics consider the incidence of injuries among the entire population, including those who do not work. This does not discount their usefulness in considering the epidemiology of upper limb injuries among the general population, as an injury sustained outside of work can affect a person’s ability to engage with their duties of work in their chosen occupation. These statistics are unsurprising given the anatomy of the upper limbs. A human’s arms are not locked into their trunk in the same way that their hips are held by tight bony ball-and-socket joints (Drake et. al., 2023). The arms have a much wider and more flexible range of motion than the lower limbs, as well as being responsible for generating power, though not as much as the legs. The arms and the hands are used to lift, carry, work, hold, turn, press, and type among so many other functions. The human visual field has evolved in such a way to coordinate the movements of the eyes with the movements of the hands and the arms (Previc, 1990; Abrams et. al., 1990; Land et. al., 1999). Upper limb movements of all breadths and intensities are required in occupations and in daily living, and so the arms are continuously under strain. When considering working populations, shoulder-and-neck, neck, shoulder, lower back, and wrist work-related musculoskeletal disorders have been found to have 12-month prevalence rates higher than forty percent in assessed populations (Govaerts et. al., 2021). The problem is even represented for my own profession of physical therapy, where work-related upper limb disorders have been found to be a persistent threat to the physical therapist workforce, likely due to the hands-on and physically intensive nature of professional activities (Waller et. al., 2022).
Safe Work Australia reports that in the 2022-2023 reporting period, the most common proportional mechanism of serious injury was due to body stressing (Safe Work Australia, 2024). Body stressing is defined as strain arising from handling, lifting, carrying, or putting down objects (SWA, 2019). The report expands on this, exploring body stressing as including muscular stress while handling, and repetitive movement. Within that report’s assessed groups, the upper limbs were always represented within the top three primary bodily locations for injury, and were most prominently represented among Trades workers, Community and personal service workers, Sales workers, Machinery operators and drivers, and Labourers, with the population of labourers reporting the highest in-group proportion of upper limb injuries, at 35%. This is understandable, given that the most common agency for serious work-related musculoskeletal disorder claims is from the use of non-powered hand-tools, appliances, and equipment. This is defined as including hand tools, fasteners, packers and packing equipment, and others. In the relevant reporting period, upper limb and lower back claims together accounted for two-thirds of all serious musculoskeletal injury claims, representing over one-third of all serious claims in the 2020-2021 period as well (SWA, 2021), and at time of writing being the highest number of claims by bodily location, as shown below in Figure 1.
Figure 1.
Claims (count) by Bodily Location
Note. Adapted from Safe Work Australia (n.d.), Key WHS statistics, Snapshot.
When considering injuries to the upper limbs, injuries can be sorted by severity and then arranged by the affected area. Upper limb injuries can be as mild as soft tissue irritations or nonserious lacerations or as severe as catastrophes that result in amputation. The diversity of severities and locations of injuries is due to the diverse range of occupations worked, the diversity of workers doing that work, and non-physical as well as non-occupational factors outside of that work that can amplify the effect of injuries upon a worker (Bongers et. al., 2002). When considering the hand, in the 2002-2004 reporting period, persons aged between 15-44 represented three-quarters of those reported injuries (Australian Safety and Compensation Council, 2008), where the greatest proportion of hospital admissions and compensation claims arose from manufacturing, construction, and other specified and unspecified work. It is notable that specified and unspecified work is used to group occupations that are not stereotypically classifiable. The most common injuries in this group were lacerations and fractures owing to having the hands caught in moving machinery, and the fingers were the most common site of injury as well as the most common location for amputation.
While the hands and fingers are often caught, cut, and crushed in their use, the forearm and elbow are also common sites of lacerations, fractures, sprains and muscular tears (Samuel, 2019). The elbows are responsible for positioning the bones of the forearm, at the ends of which are the wrists and the hands. The muscles of the forearm provide power to and coordination of the wrist and the fingers, and some originate from promontories of bone at the end of the humerus, the upper bone of the arm. The elbow is three joints in one, allowing bending, turning, twisting, and transfer of force through the arm. Higher strain increases the risk of irritation through the elbow and likelihood of subsequent injury (Bretschneider et. al., 2021). This risk can be increased with load-handling, tool-handling, high-grip forces, static work using tools and static work using the hands (van Rijn et. al., 2009). The risks apply to non-tool users as well, where hand and wrist support while working have been found to improve fatigue levels in the muscles positioning and loading the elbow (Callegari et. al., 2018), potentially minimising the likelihood and severity of soft-tissue syndromes which may be general and diffuse (Helliwell, 1999), by decreasing the loading of the forearm extensor musculature (Keir & Wells, 2002). The elbows and the shoulders are used to steady and direct the arms in pushing and pulling tasks, where the regularity and loading of pushing and pulling tasks gives rise to shoulder symptoms (Hoozemans et. al., 2014) owing to differences in handling postures due to diverse worker anatomy (Domizio & Keir, 2010), handling ergonomics (Seo et. al., 2010), and where combined exposures may give rise to increased strain risk (Chiarotto et. al., 2023). Acute exposures to force and awkward postures can occur when using powered and unpowered tools where catching, kickback, or locking of tools like handsaws, shears, and grinders can send rotational torque back up into the tool grip and into the user’s arm, resulting in an acute exposure to high-frequency, high-amplitude vibration which can cause tissue, nerve, and vascular damage (Radwin et. al., 1987; ASCC, 2008).
The upper limb and shoulder are common points of injury and irritation; these structures position the arm relative to the trunk and are also responsible for anchoring the long bone of the humerus into the shoulderblade and arranging the entire upper limb on the torso. The shoulderblade is only directly connected to the trunk by the collarbone, and indirectly by the scaffold of muscles over the back, which are balanced by the pectoral muscles of the chest into a girdle which has evolved to withstand heavy physical demands and to do so over an unusually wide range of motion. However, its flexibility, complexity, and the nature of demands imposed on the shoulder makes it susceptible to a range of irritations and injuries, particularly under conditions in which it is excessively overloaded (Linaker & Walker-Bone, 2015). Given the shoulder’s closeness to the neck, symptoms arising from the neck are frequently referred into the shoulder, as well as vice-versa. This co-referral can mean that shoulder muscle strain can be associated with headaches, nausea, and dizziness, which may be misdiagnosed and therefore inappropriately managed (Fish et. al., 2011). In spite of this complexity, management is largely simplistic, consisting of continued attendance at work, ergonomic modification, job task modification, and modification of the working space (Health and Safety Executive (HSE), 2003). Occupational risk factors such as lifting, especially at or above shoulder height, awkward postures and the duration of a worker’s shift can be further magnified by exposure to repetitious or forceful work, vibration or percussion, and inconsistent work demands which do not allow workers time to rest and recuperate (Van der Windt et. al., 2000; Andersen et. al., 2003). These risk factors may have a greater or lesser accumulative effect depending on the worker’s age, gender, experience with that job, and non-occupational factors such as smoking and drinking history and general physical fitness (Govaerts et. al., 2021).
Managing the loading of the upper limbs to prevent irritation, injury, and minimise the likelihood of adverse incidents depends on the workplace, the workspace, and the worker in question. No two of these variables are ever the same, and so one-size-fits-all approaches are never appropriate. Workers use their arms outside of work in similar patterns of movement and action as they do during work - instead of carrying bags they may carry baskets of laundry, instead of sitting at a desk they may browse the internet at home, and chefs always need to cook. It is also necessary to remember the effect of psychosocial and non-occupational factors on the presentation of pain in a worker, some elements of which may be more or less controllable as a function of work design (Tang, 2022). Effective general controls include the minimisation of repetitive high-speed movements as an effective means of minimising upper limb musculoskeletal disorders, decreasing loads for manual handling, and minimising worker exposure to tension-eliciting postures such as static holds and extended grips (Arvidsson et. al., 2021). More comprehensive controls include work station and task adjustment that allows a worker to unload their arms from static postures with appropriate support, such as wrist and forearm support when typing or adjusting the working surface to minimise tendon strain (Erdelyil et. al., 1988; Xu & Shin, 2012; Callegari et. al., 2018). However, it is again notable that while all workers must use similar anatomies, the nature of work varies between industries, between companies, and between workstations. Individually prescribed stretching exercises undertaken at regular intervals have been found to be protective against accumulative strain resulting from sustained or otherwise stereotypical postures, but it has also been found that if stretching or other exercise-based intervention is prescribed or undertaken inappropriately, it might exacerbate the effect of these exposures, rather than mitigate them (Da Costa & Vieira, 2008). Within examined occupational contexts, vibration, the assumption of awkward postures, sustained grip and sustained repetitive precision movements performed over prolonged periods (Latko et. al., 1999), as well as inappropriate workplace ergonomics resulting in maladaptive worker strategies are common causes of muscular strain and the development of upper limb musculoskeletal pain (Greggi et. al., 2024).
Workers in every industry need to use their hands, their arms, and their bodies to complete their job tasks. Every job task exposes that worker to forces large and small, applied over short or sustained time periods, with rest periods inbetween, for the durations of their shifts and over the length of their working lives. The worker is a human (citation needed), and so must also use human capacities to do non-work related human things using the same body that is used to work. The stress to which a worker is exposed in their duties of work has impacts on their ability to live their lives comfortably, especially when that stress is applied to the upper limbs and the hands. Humans must write, type, eat, hold, and embrace with their hands and their arms. Humans must work, lift, carry, pull, and push with their hands and their arms. The forces to which the arms and shoulder girdles are exposed over the span of a human life leave little ambiguity as to why upper limb disorders are some of the most comprehensively disabling injuries a person can experience, or why upper limb injuries take excessive time and money to resolve. Even beyond the injury, the impact of physical pain that has a disabling effect on a person cannot be overstated - an impact that impairs their ability to meet their own needs outside of work, to be themselves, and to live life in the way that they want to.
Technological and societal advancement has increased the complexity of work and the intensity of the forces to which workers are exposed. Even if a worker is using unpowered tools, they are still leveraging forces beyond their ability to produce in order to accomplish tasks beyond the capacity of a normal human. This exposure to force is an exposure to risk, and that risk affects the body through points of entry and concentration. All occupations require hand and arm engagement, and so all workers are vulnerable to upper limb discomfort and disorders to a greater or lesser degree. The ability to grasp something with the palm is present since birth and persists throughout life - the use of the upper limbs is as central to being human as being able to walk upright, and to protect the upper limbs is to protect a person’s ability to engage, to hold, and to reach.
How else can you seize the day?
None of this information constitutes medical, legal, occupational health and safety, best guidance, standard, or other guidance, instruction, or prescription.
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