PRINCIPLES AND APPLICATIONS

IN ENGINEERING SERIES

OCCUPATIONAL
ERGONOMICS
Engineering and
Administrative Controls

PRINCIPLES AND APPLICATIONS

IN ENGINEERING SERIES

OCCUPATIONAL
ERGONOMICS
Engineering and
Administrative Controls
EDITED BY

Waldemar Karwowski
University of Louisville
Louisville, Kentucky

William [Link]
The Ohio State University
Columbus, Ohio

CRC PRESS
Boca Raton London New York Washington, D.C.

This edition published in the Taylor & Francis e-Library, 2005.

To purchase your own copy of this or any of Taylor & Francis or Routledges
collection of thousands of eBooks please go to [Link].
This material was previously published in The Occupational Ergonomics Handbook. CRC Press LLC 1999.

Library of Congress Cataloging-in-Publication Data

Occupational ergonomics: engineering and administrative controls/edited by Walidemar
Karwowski, William [Link].
p. cm.(Principles and applications in engineering; 14)
Includes bibliographical references and index.
ISBN 0-8493-1800-9
1. Human engineering. 2. Musculoskeletal systemWounds and injuriesPrevention.
3. Industrial hygiene. I. Karwowski, Waldemar. II. Marras, William S. (William Steven),
1952- III. Series.
TA166.O257 2003
620.8'2dc21
2002041399

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The Editors

Waldemar Karwowski, Ph.D., P.E., C.P.E., is Professor of

Industrial Engineering and Director of the Center for Industrial
Ergonomics at the University of Louisville, Kentucky. He holds
an M.S. (1978) in production management from Technical
University of Wroclaw, Poland, and a Ph.D. (1982) in Industrial
Engineering from Texas Tech University. His research, teaching,
and consulting activities focus on prevention of low back injury
and cumulative trauma disorders, human and safety aspects of
advanced manufacturing, fuzzy sets and systems, and theoretical
aspects of ergonomics.
Dr. Karwowski served as President (20002003) of the
International Ergonomics Association. He is editor of many
international journals, including Human Factors and Ergonomics
in Manufacturing, and Theoretical Issues in Ergonomics Science, and consulting editor of
Ergonomics. He is the author or co-author of more than 200 scientific publications, including
25 books.
Dr. Karwowski is founder and chairman of the International Conference on Human Aspects
of Advanced Manufacturing and Hybrid Automation. He was the recipient of the Outstanding
Young Engineer of the Year Award, given by the Institute of Industrial Engineering. He was
also a Fulbright Scholar at Tampere University of Technology in Finland. He received the
Presidents Award for Outstanding Scholarship, Research, and Creative Activity in the category
of Basic and Applied Science at the University of Louisville.
William [Link], Ph.D., C.P.E., holds the Honda Endowed
Chair in Transportation in the Department of Industrial,
Welding, and Systems Engineering at The Ohio State University,
Columbus. He is also the director of the biodynamics laboratory
and holds appointments in the departments of physical medicine
and biomedical engineering. Professor Marras is also the codirector of the Ohio State University Institute for Ergonomics.
Dr. Marras received his Ph.D. in bioengineering and
ergonomics from Wayne State University in Detroit, Michigan.
His research centers around biomechanical epidemiologic
studies, laboratory biomechanic studies, mathematical
modeling, and clinical studies of the back and wrist.
His findings have been published in more than 100 refereed
journal articles and 12 book chapters, and he holds two patents, including one for the lumbar
motion monitor (LMM). His work has also attracted national and international recognition.
He has won the prestigious Swedish Volvo Award for Low Back Pain Research and Austrias
Vienna Award for Physical Medicine.
v

Contributors

Elsayed Abdel-Moty
Department of Industrial
Engineering
University of Miami
Coral Gables, Florida

Patrick [Link]
Liberty Mutual Research
Center for Safety and Health
Hopkinton, Massachusetts

[Link] Allread
The Ohio State University
Columbus, Ohio

Bradley Evanoff
School of Medicine
Washington University
St. Louis, Missouri

Charles [Link]
Advanced Ergonomics, Inc.
Dallas, Texas

Paul Gaddie
University of Louisville
Louisville, Kentucky

Gunnar [Link]
Department of Orthopedic
Surgery
St. Lukes Medical Center
Chicago, Illinois

Katharyn [Link]
Robert [Link] Laboratories
National Institute for
Occupational Safety and
Health
Cincinnati, Ohio

Michele [Link]
Department of Orthopaedics
University of Washington
Seattle, Washington
Patricia Bertsche
The Ohio State University
Columbus, Ohio
Ram Bishu
IMSE Department
University of Nebraska
Lincoln, Nebraska
[Link] Burton
Department of Clinical
Biomechanics
Huddersfield Polytechnic
Huddersfield, England
Don [Link]
Center for Ergonomics
University of Michigan
Ann Arbor, Michigan

Thomas Hales
National Institute for
Occupational Safety and
Health
Cincinnati, Ohio
Simon [Link]
Liberty Mutual Research
Center for Safety and Health
Hopkinton, Massachusetts
Renliu Jang
University of Louisville
Louisville, Kentucky
Waldemar Karwowski
Department of Industrial
Engineering
University of Louisville
Louisville, Kentucky
Glenda [Link]
Key Functional Assessments
Minneapolis, Minnesota

Tarek [Link]
Department of Industrial
Engineering
University of Miami
Coral Gables, Florida
Jung-Yong Kim
Department of Industrial
Engineering
Hanyang University
Ansan, Korea
Stephan Konz
Department of IMSE
Kansas State University
Manhattan, Kansas
Steven [Link]
Department of Orthopedic
Surgery
St. Lukes Medical Center
Chicago, Illinois
Wook Gee Lee
University of Louisville
Louisville, Kentucky
Chris [Link]
Department of Behavioural
Medicine
Hope Hospital
Salford, England
Richard [Link]
Department of Mechanical and
Industrial Engineering
Marquette University
Milwaukee, Wisconsin
William [Link]
ISE Department
The Ohio State University
Columbus, Ohio
vii

Stuart [Link]
University of Waterloo
Waterloo, Ontario, Canada
Raymond [Link]
Liberty Mutual Research
Center for Safety and Health
Hopkinton, Massachusetts
Donald [Link]
Interlogics
Hillsborough, North Carolina
Stephen [Link]
State of Oregon
OSHA
Portland, Oregon
[Link]
University of Nebraska
Lincoln, Nebraska
Robert [Link]
Department of Kinesiology
University of Waterloo
Waterloo, Ontario, Canada
Ewa Nowak
Department of Ergonomics
Research
Institute of Industrial Design
Warsaw, Poland
Mohamad Parnianpour
Department of ISE
The Ohio State University
Columbus, Ohio

Malcolm [Link]
Department of Orthopaedic
Surgery
Iowa Spine Research Center
University of Iowa
Iowa City, Iowa
Vern Putz-Anderson
Applied Psychology and
Ergonomics
National Institute for
Occupational Safety and
Health
Cincinnati, Ohio

Renee Steele-Rosomoff
Comprehensive Pain and
Rehabilitation Center
University of Miami
Coral Gables, Florida
Aboulfazl Shirazi-Adl
cole Polytechnique
Montreal, Quebec, Canada
Carolyn [Link]
ISE Department
The Ohio State University
Columbus, Ohio

Robert [Link]
Department of Industrial
Engineering
University of Wisconsin
Madison, Wisconsin

Leon [Link]
Curtin University of
Technology
Shenton Park, Australia

David Rempel
University of California
San Francisco, California

Carol Stuart-Buttle
Stuart-Buttle Ergonomics
Philadelphia, Pennsylvania

Valerie [Link]
U.S. Army Research Institute of
Environmental Medicine
Occupational Physiology
Division
Natick, Massachusetts

Eira Viikari-Juntura
Department of Physiology
Finnish Institute of
Occupational Health
Topeliuksenkatu, Finland

Richard [Link]
The Ohio State University
Columbus, Ohio
Stephen [Link]
San Francisco General Hospital
San Francisco, California
Hubert [Link]
Comprehensive Pain and
Rehabilitation Center
University of Miami
Coral Gables, Florida

Thomas [Link]
National Institute for
Occupational
Safety and Health
Cincinnati, Ohio
Richard Wells
Department of Kinesiology
University of Waterloo
Waterloo, Ontario, Canada

Contents

Preface

xiii

PART I MUSCULOSKELETAL DISORDERS

SECTION I Disorders of the Extremities

Epidemiology of Upper Extremity Disorders Bradley Evanoff and David Rempel

1-1

Integrated Analysis of Upper Extremity Disorders

2-1

Biomechanical Aspects of CTDs Richard [Link]

3-1

Occupational Risk Factors for Shoulder Disorders Eira Viikari-Juntura

4-1

Hand Tools: Design and Evaluation Robert [Link]

5-1

Gloves Ram Bishu and [Link]

6-1

Industrial Mats Jung-Yong Kim

7-1

Ergonomic Principles Applied to the Prevention of Injuries to the

Lower Extremity Steven [Link] and Gunnar [Link]

8-1

Ergonomics of the Foot

9-1

Richard Wells

Stephan Konz

SECTION II Low Back Disorders

10

Epidemiology of Back Pain in Industry Gunnar [Link]

10-1

11

Static Biomechanical Modeling in Manual Lifting Don [Link]

11-1

ix

12

Dynamic Low Back Models: Theory and Relevance in Assisting the

Ergonomist to Reduce the Risk of Low Back Injury Stuart [Link]

12-1

Selection of 2-D and 3-D Biomechanical Spine Models: Issues for

Consideration by the Ergonomist Robert [Link] and Stuart [Link]

13-1

Quantitative Assessment of Trunk Performance Mohamad Parnianpour and

Aboulfazl Shirazi-Adl

14-1

15

Perspective on Industrial Low Back Pain Malcolm [Link] and Donald [Link]

15-1

16

Revised NIOSH Lifting Equation

16-1

17

A Population-Based Load Threshold Limit (LTL) for Manual Lifting Tasks

Performed by Males and Females Waldemar Karwowski, Paul Gaddie,
Renliu Jang, and Wook Gee Lee

17-1

Occupational Low Back Disorder Risk Assessment Using the Lumbar Motion
Monitor William [Link], [Link] Allread, and Richard [Link]

18-1

Prevention of Musculoskeletal Disorders: Psychophysical Basis

Patrick [Link]

19-1

The Relative Importance of Biomechanical and Psychosocial Factors

in Low Back Injuries [Link] Burton, Michele [Link], and Chris [Link]

20-1

21

Fall-Related Occupational Injuries Stephen [Link]

21-1

22

Low Back Pain (LBP) Glossary: A Reference for Engineers and Ergonomists
Simon [Link] and Raymond [Link]

22-1

13
14

18
19
20

Thomas [Link] and Vern Putz-Anderson

PART II ADMINISTRATIVE CONTROLS

SECTION I Ergonomics Surveillance

23
24

Fundamentals of Surveillance for Work-Related Musculoskeletal Disorders

Vern Putz-Anderson and Katharyn [Link]

23-1

Injury Surveillance Database Systems Carol Stuart-Buttle

24-1

25

OSHA Recordkeeping

26

Body Discomfort Assessment Tools

Stephen [Link]

25-1

Leon [Link]

26-1

SECTION II Medical Management Prevention

27

Medical Management of Work-Related Musculoskeletal Disorders

Thomas Hales and Patricia Bertsche

27-1

Ergonomic Programs in Post-Injury Management Tarek [Link],

Elsayed Abdel-Moty, Renee Steele-Rosomoff, and Hubert [Link]

28-1

29

Physical Ability Testing for Employment Decision Purposes Charles [Link]

29-1

30

Preplacement Strength Screening Valerie [Link]

30-1

31

Assessment of Worker Functional Capacities

31-1

32

Ergonomics and Rehabilitation Ewa Nowak

32-1

33

Update on the Use of Back Belts in Industry: More DataSame Conclusion

Stuart [Link]

33-1

The Influence of Psychosocial Factors on Sickness Absence Chris [Link],

[Link] Burton, and Michele [Link]

34-1

Back Pain in the Workplace: Implications of Injury and Biopsychosocial

Models Michele [Link], Chris [Link], and [Link] Burton

35-1

Upper Extremity Support Carolyn [Link]

36-1

28

34
35
36

Index

Glenda [Link]

I-1

xi

Preface

Ergonomics (or human factors) is defined by the International Ergonomics Association

([Link]) as the scientific discipline concerned with the understanding of interactions
among humans and other elements of a system, and the profession that applies theory,
principles, data and methods to design in order to optimize human well-being and overall
system performance. Ergonomists contribute to the design and evaluation of tasks, jobs,
products, environments, and systems in order to make them compatible with the needs, abilities,
and limitations of people.
Currently, there is substantial and convincing evidence that the proficient application of
ergonomics knowledge, in a system context, will help to improve system effectiveness and
reliability, increase productivity, reduce employee healthcare costs, and improve the quality
of work processes, products and working life for all employees. As ergonomics promotes a
holistic approach in which considerations of physical, cognitive, social, organizational,
environmental and other relevant factors are taken into account, the professional ergonomists
should have a broad understanding of the full scope of the discipline. Development of this
book was motivated by the quest to facilitate a wider acceptance of ergonomics as an effective
methodology for work-system design aimed at improving the overall quality of life for millions
of workers with a variety of needs and expectations.
This book focuses on prevention of work-related musculoskeletal disorders with emphasis
on engineering and administrative controls. This volume contains a total of 36 chapters divided
into two parts, each of which is divided into two sections.
Part I focuses on engineering factors relevant to management of work-related
musculoskeletal disorders. Section I provides knowledge about risk factors for upper and
lower extremities at work, while Section II concentrates on risk factors for work-related low
back disorders. The knowledge presented in Section I includes epidemiology, biomechanics,
and analysis of upper extremity disorders. This section also includes discussion of occupational
risk factors, shoulder, design and evaluation of handtools, gloves, and industrial mats. In
addition, information about injuries to the foot and leg is provided. The section on low back
disorders includes knowledge on epidemiology of back pain in industry, static and dynamic
low back biomechanical modeling, quantitative assessment of trunk performance, revised
NIOSH equation, and population-based limits for manual lifting. In addition, this section
discusses psychophysical basis and psychosocial factors in preventing musculoskeletal disorders.
It also includes a method for assessment of risk of occupational low back disorders,
occupational injuries due to falls, and provides a useful glossary of low back pain terminology.
Part II focuses on administrative controls in prevention and management of musculoskeletal
disorders. Section I discusses fundamentals of surveillance of such disorders, requirements
for surveillance database systems, OSHA record keeping system, and surveillance methods
xiii

based on assessment of body discomfort. Section II focuses on medical management of workrelated musculoskeletal disorders, including programs for post-injury management, testing
of physical ability for employment decisions, assessment of worker strength and other
functional capacities, and applications of ergonomics knowledge in rehabilitation.
The use of back belts and supporting devices for upper extremities is also considered.
Finally, the influence of psychosocial factors and implications of back pain in the workplace
is provided.
We hope that this volume will be useful to a large number of professionals, students, and
practitioners who strive to improve product and process quality, worker health and safety,
and productivity in a variety of industries and businesses. We trust the knowledge presented
in this volume will help the reader learn and apply the principles of ergonomics in prevention
of work-related musculoskeletal disorders.

Waldemar Karwowski
University of Louisville
WIlliam [Link]
The Ohio State University

xiv

Part I
Musculoskeletal
Disorders

Section I
Disorders of the
Extremities

1
Epidemiology of Upper
Extremity Disorders
Bradley Evanoff
Washington University School
of Medicine

David Rempel
University of California
San Francisco

1.1
1.2
1.3
1.4
1.5

Frequency, Rates, and Costs

Disorder Types and their Natural History
Individual Factors
Work-Related Factors
Summary

11
12
13
14
17

This chapter summarizes findings from epidemiologic studies that address workplace and individual
factors associated with upper extremity musculoskeletal disorders. These disorders are not new: epidemics
and clinical case series of work-related upper extremity problems were reported throughout the 1800s
and early 1900s (Conn, 1931; Thompson et al., 1951). Although there are almost no prospective studies
in this area, within the last 20 years a number of well-designed, cross-sectional studies have focused on
disorders of the hand, wrist, and elbow as related to work. These studies point to the multifactorial
nature of work-related upper extremity disorders. The severity of these disorders is influenced not only
by biomechanical factors, but also by other work organizational factors, the workers perception of the
work environment, and medical management.
From an epidemiologic point of view, this topic is problematic because there are many specific disorders
that can occur in the hand, arm, and shoulder, ranging from arthritis to nerve entrapments. To complicate the
matter further, there are few accepted criteria for case definitions for these many disorders. In their early
stages, these disorders usually present with nonspecific symptoms without physical examination or laboratory
findings. In fact, the only laboratory tests consistently of value in diagnosing these disorders are nerve conduction
studies for nerve entrapment disorders and radiographs for osteoarthritis. Finally, symptoms at the hand or
wrist may be due to nerve compression or vascular pathology in the neck or shoulder.

1.1 Frequency, Rates, and Costs

Rates of hand and wrist symptoms and associated disability among working adults were assessed by a
1988 national interview survey of 44,000 randomly selected U.S. adults (National Health Interview
Survey) (Park et al., 1993). Of those who had worked anytime in the past 12 months, 22% reported
some finger, hand, or wrist discomfort that fit the category pain, burning, stiffness, numbness, or
tingling for one or more days in the past 12 months. Only one-quarter were due to an acute injury such
as a cut, sprain, or broken bone. Nine percent reported having prolonged hand discomfort that was not
due to an acute injury; that is, discomfort of 20 or more days or 7 or more consecutive days during the
last 12 months. Of those with prolonged hand discomfort, 6% changed work activities and 5% changed
jobs due to the hand discomfort.

0-8493-1800-9/03/$0.00+$1.50
2003 by CRC Press LLC

1-1

1-2

Occupational Ergonomics: Engineering and Administrative Controls

TABLE 1.1 Examples of Disorders of the Hand, Wrist, and Elbow
Observed in Workplace Studies

Elbow pain and epicondylitis are common in working populations. Symptoms of elbow pain are
reported by 7 to 21% of workers in industrial populations (Chiang et al., 1993; Ohlsson, 1989; Buckle,
1987). Epicondylitis is seen in 0.7 to 2.0% of workers in jobs with low levels of physical demands to the
arms and hands, and in 2 to 33% of worker groups with high levels of demands.
In the U.S., hand and wrist disorders account for 55% of all work-related repeated motion disorders
reported by U.S. private employers (Bureau of Labor Statistics, 1993). This category excludes low back
pain. A similar percentage is also reported in industrial (McCormack et al., 1990) and other national
studies (Kivi, 1984). A similar rise in work-related hand/forearm problems has been observed in other
countries such as Finland (Kivi, 1984), Australia (Bammer, 1987), and Japan (Ohara et al., 1976).
Costs for work-related musculoskeletal disorders are difficult to estimate reliably. Webster and Snook
(1994) analyzed 1989 insurance claims data from 45 states, restricting their analysis to upper extremity
claims classified as cumulative trauma disorders. They estimated that the total compensable cost for
upper extremity cumulative trauma disorders in the U.S. was $563 million in 1989. The National Institute
for Occupational Safety and Health has estimated that the annual workers compensation costs for neck
and upper extremity disorders is $2.1 billion, plus $90 million in indirect costs (NIOSH, 1996).

1.2 Disorder Types and their Natural History

Table 1.1 lists the most common workplace hand, wrist, and elbow problems. Nonspecific hand/wrist
pain is the most common problem, followed by tendinitis, ganglion cysts, and carpal tunnel syndrome.
(Silverstein et al., 1987; McCormack et al., 1990; Hales et al., 1994). In many workplace studies, rates
of nonspecific symptoms, tendinitis, and CTS appear to track each other, that is, a number of specific
disorders typically occur together. For example, in a pork processing plant, the rank order of hand and
wrist problems, as a percentage of all morbidity, was: nonspecific hand/wrist pain (39%), CTS (26%),
trigger finger (23%), trigger thumb (17%), and DeQuervains tenosynovitis (17%) (Moore and Garg,
1994). Similar ratios of disorders have been observed in manufacturing (Armstrong et al., 1982; Silverstein
et al., 1986; McCormack et al., 1990), food processors (Kurppa et al., 1991; Luopajrvi et al., 1979),
and among computer operators (Hales et al., 1994; Bernard et al., 1993).
Tendinitis is the most common specific, work-related hand disorder (McCormack, 1990; Luopajarvi,
1979). For the purposes of this chapter tendinitis will include hand, wrist, and distal forearm tendinitis
or tenosynovitis, and trigger finger. Tendinitis occurs at discrete locations; the most common site is the
first extensor compartment (De Quervains Disease), followed by the five other pulley sites on the extensor
side of the hand and three on the flexor side. The diagnosis is based on history, symptom location, and
palpation and provocative maneuvers on physical exam. There has been no association of tendinitis
with age or gender, but work-related tendinitis is higher among workers with less than 3 years of
employment (McCormack et al., 1990).
Lateral epicondylitis is the most common specific elbow disorder; medial epicondylitis is less common.
The diagnosis is based on pain and tenderness over the lateral or medial elbow and pain on movement
of the wrist or fingers against resistance. Other disorders of the elbow which may be related to occupational
activities include olecranon bursitis, triceps tendinitis, and osteoarthritis.

Epidemiology of Upper Extremity Disorders

1-3

Studies of carpal tunnel syndrome have generated considerable controversy. While there is agreement
that this disorder results from compression of the median nerve at the wrist, there are no universally
accepted diagnostic criteria for carpal tunnel syndrome. Some consider an abnormal nerve conduction
study a gold standard (Katz et al., 1991; Nathan et al., 1992; Heller et al., 1986). However, relying
exclusively on nerve conduction studies can lead to reporting very high prevalence rates28% (Nathan
et al., 1992) and 19% (Barnhart et al., 1991) in low-risk working populations. A case definition
incorporating typical symptoms and signs has been proposed by NIOSH for surveillance purposes (CDC,
1989); however, the usual signs have relatively poor sensitivities and specificities (Katz et al., 1991;
Heller et al., 1986; Franzblau et al., 1993). Therefore, this definition may have limited value in
distinguishing CTS from other hand disorders. Hand diagrams completed by patients are reproducible
and sensitive, but may lack specificity (Katz et al., 1990; Franzblau et al., 1994). Only in the later stages
are weakness and thenar atrophy a noticeable feature. In approximately 25% of cases, CTS is accompanied
by other disorders of the hand or wrist (Phalen, 1966).
Few studies have evaluated the work-relatedness of osteoarthritis of the hand and wrist (Hadler et
al., 1978; Williams et al., 1987). Hadler et al. (1978) assessed the hands of 67 workers at a textile plant
in Virginia. Significant differences in finger and wrist joint range of motion, joint swelling, and X-ray
patterns of degenerative joint disease were observed between three different hand intensive jobs; the
observed differences matched the pattern of hand usage.
Hand arm vibration syndrome or Vibration White Finger disease occurs in occupations involving
many years of exposure to vibrating hand tools (NIOSH, 1989). This is a disorder of the small vessels
and nerves in the fingers and hands presenting as localized blanching at the fingertips with numbness on
exposure to cold or vibration. The symptoms are largely self-limited if vibration exposure is eliminated
at an early stage (Ekenvall and Carlsson, 1987; Futatsukal and Ueno, 1986).
Hypothenar hammer syndrome or occlusion of the superficial palmar branch of the ulnar artery has
been associated in clinical series and case-control studies with habitually using the hand for hammering
(Little and Ferguson, 1972; Nilsson et al., 1989) and with exposure to vibrating hand tools (Kaji et al.,
1993). The mean years of exposure before presentation were 20 to 30 years.
Small case-control studies or clinical series have described factors associated with less common disorders
such as Gamekeepers thumb (Campbell, 1955; Newland, 1992), digital neuritis, and ulnar neuropathy
at the wrist (Silverstein et al., 1986).

1.3 Individual Factors

Some data on individual risk factors, such as age and gender, are available for carpal tunnel syndrome
but not for other disorders of the hand and wrist. The risk of CTS increases with age (Stevens et al.,
1988), but in a cross-sectional study of an industrial cohort, age explained only 3% of the variability in
median nerve latency (Nathan et al., 1992). Although CTS is more common among women in the
general population, in workplace studies, when employees perform similar hand activities, the ratio of
female to male rates is close to 1.2:1 (Franklin et al., 1991; Nathan et al., 1992; Silverstein et al., 1986).
Certain female-specific factors, such as pregnancy (Eckman-Ordeberg et al., 1987) are clearly associated
with CTS; however, the role of other female factors such oophorectomy, hysterectomy (Cannon et al.,
1981; Bjorkquist et al., 1977; de Krom et al., 1990), or use of oral contraceptives (Sabour, 1970), is less
certain. Other individual factors have strong associations with carpal tunnel syndrome based on multiple
studies: diabetes mellitus (Phalen, 1966; Yamaguchi et al., 1965; Stevens et al., 1987), rheumatoid
arthritis (Phalen, 1966; Yamaguchi et al., 1965; Stevens et al., 1987), and obesity (Nathan et al., 1992;
de Krom et al., 1990; Falck and Aarnio, 1983; Vessey et al., 1990; Werner et al., 1994). For some
putative risk factors, the associations are based on single studies on studies presenting conflicting results:
thyroid disorders (Phalen, 1966; Hales et al., 1994), vitamin B6 deficiency (Amadio, 1985; Ellis et al.,
1982; McCann, 1978), wrist size and shape (Johnson et al., 1983; Armstrong and Chaffin, 1979; Bleeker

1-4

Occupational Ergonomics: Engineering and Administrative Controls

TABLE 1.2 Work-Related Factors Associated with
Disorders of the Hands and Wrists

TABLE 1.3 Controlled Epidemiologic Workplace Studies Evaluating the Association between Work and Wrist,
Hand or Distal Forearm Tendinitis*

* Case criteria are based on history and physical examination.

1
significant difference from control
2
adjusted for age, sex, and plant
3
analysis includes other disorders, although tendinitis was most common
4
cohort study with 31-month follow-up
5
all exposed and control subjects are female
From Rempel, D. and Punnet, L., Epidemiology of wrist and hand disorders, in Musculoskeletal Disorders in the
Workplace: Principles and Practice, eds. [Link] et al., Mosby-Year Book, Inc., St. Louis, Missouri, 1997. With
permission.

et al., 1985), and general de-conditioning (Nathan et al., 1988, 1992).

1.4 Work-Related Factors

Table 1.2 summarizes the characteristics of work that have been associated with elevated rates of upper
extremity symptoms and specific disorders, including carpal tunnel syndrome and tendinitis. These
associations have been observed in multiple studies and in different population groups, while doseresponse trends have been seen in several studies. Most studies have been cross-sectional in design,
limiting our ability to draw conclusions about causation. The preponderance of evidence, however,
suggests strongly that there is a causal relationship between work exposures and upper extremity disorders.
Carpal tunnel syndrome and hand-wrist tendinitis have been the best studied; several recent reviews
have evaluated the work-relatedness of these disorders and concluded that there is a causal relationship
(Stock, 1991; Hagberg et al., 1992; Kuorinka and Forcier, 1995). Tables 1.3, 1.4, and 1.5 summarize
selected studies of wrist and hand tendinitis, carpal tunnel syndrome, and epicondylitis.
Studies using crude measures of exposure have reported associations between repetition and hand/
wrist pain and disorders. In a study relying exclusively on nerve conduction measurements, median
nerve slowing occurred at a higher rate among assembly line workers than among administrative controls

Epidemiology of Upper Extremity Disorders

1-5

TABLE 1.4 Selected Controlled Epidemiologic Workplace Studies Evaluating the Association between Work and
Carpal Tunnel Syndrome*

* Diagnosis based on history and physical exam or nerve conduction study.

1
significantly different from control group
2
control for age, gender, years on job
3
control for age and gender
4
low participation rate and limited exposure assessment
From Rempel, D. and Punnet, L., Epidemiology of wrist and hand disorders, in Musculoskeletal Disorders in the
Workplace: Principles and Practice, eds. [Link] et al., Mosby-Year Book, Inc., St. Louis, Missouri, 1997. With
permission.
TABLE 1.5 Selected Epidemiologic Workplace Studies Evaluating the Association between Work and Epicondylitis*

* Diagnosis based on history and physical exam.

1
prospective cohort study: rates are incidence of epicondylitis per 100 workers/yr
2
cross-sectional study: rates are prevalence of epicondylitis observed in active workers

1-6

Occupational Ergonomics: Engineering and Administrative Controls

(Nathan et al., 1992; Hagberg et al., 1992). Although no systematic assessment of exposure was carried
out, the assembly line work was considered more repetitive than the control group. Rate of persistent
wrist and hand pain was higher in garment workers performing repetitive hand tasks than in the control
group, hospital employees (Punnett et al., 1985). Persistent wrist pain, or that lasting most of the day for
at least one month in the last year, occurred in 17% of garment workers and 4% of hospital controls,
while persistent hand pain occurred in 27% of garment workers and 10% of controls. Others have
observed a similar link between high hand/wrist repetition and carpal tunnel syndrome (Chiang et al.,
1990; Barnhart et al., 1991) and tendinitis (Kurppa et al., 1991). The link to repetition may be that
these are jobs that require high velocity or accelerations of the wrist (Marras and Schoenmarklin, 1993).
Rates of wrist tendinitis among scissors makers was compared to shop attendants in department stores
in Finland. Examinations and histories were systematized and performed by one person. The rates between
the groups were not significantly different; however, among the scissors makers the rate of tendinitis
increased with increasing number of scissors handled (Kuorinka and Koskinen, 1979). Luopajrvi et al.
(1979) compared packers in a bread factory to the same control group. The packers work involved
repetitive gripping, up to 25,000 cycles per day, with maximum extension of thumb and fingers to handle
wide bread packages. Approximately half of the packers had wrist/hand tenosynovitis compared to 14%
among the controls. The most common disorder of the hand or wrist was thumb tenosynovitis followed by
finger/wrist extensor tenosynovitis. CTS was diagnosed in four packers and no controls.
The force applied to a tool or materials during repeated or sustained gripping are also predictors of
risk for tendinitis and carpal tunnel syndrome. For example, in a study of the textile industry the risk of
hand and wrist tendinitis was 3.9 times higher among packaging and folding workers than among
knitters (McCormack et al., 1990). The packing and folding workers were considered to be performing
physically demanding work compared to the knitting workers. Armstrong et al. (1979) observed that
women with carpal tunnel syndrome applied more pinch force during production sewing than did their
job- and sex-matched controls. It is possible that those with carpal tunnel syndrome altered their working
style as the carpal tunnel syndrome progressed; however, it is unlikely that they would increase the pinch
force because this would also trigger symptoms. In a study by Moore et al. (1994) at a pork processing
plant, the jobs that involved high grip force or long grip durations, such as Wizard knife operator,
snipper, feeder, scaler, bagger, packer, hanger, and stuffer, affected almost every employee. Others have
observed a similar relationship with work involving sustained or high-force grip in grinders (Nathan et
al., 1992), meatpackers and butchers (Kurppa et al., 1991; Falck and Aarnio, 1983), and other industrial
workers (Thompson et al., 1951; Welch, 1972).
The most comprehensive study of the combined factors of repetition and force was a cross-sectional
study of 574 industrial workers by Silverstein et al. (1986, 1987; Armstrong, 1982). Disorders were
assessed by physical exam and history and were primarily tendinitis followed by carpal tunnel syndrome,
Guyon tunnel syndrome, and digital neuritis. Subjects were classified into four exposure groups based
on force and repetition. The high-force work was that requiring a grip force on average of more than
4 kg-force, while low-force work required less than 1 kg of grip force. The high-repetition work
involved a repetitive task in which either the cycle time was less than 30 seconds (greater than 900 times
in a work day) or more than 50% of cycle time was spent performing the same kind of fundamental
movements. The high-risk groups were compared to the low-risk group after adjusting for plant, age,
gender, and years on the job. The odds ratio of all hand/wrist disorders for just high force was 4.9, and
it increased to 30 for jobs which required both high-force and high-repetition. The identical analysis of
just carpal tunnel syndrome revealed an odds ratio of 1.8 for force and 14 for the combined high-force
and high-repetition group. A meta-analysis of Silversteins data and Luopajrvi study concluded that for
high-force and high-repetition work the common odds ratio for carpal tunnel syndrome was 15.5 (95%
C.I. 1.7141) and for hand/wrist tendinitis it was 9.1 (95% C.I. 516) (Stock, 1991). Estimates of the
percentage of CTS cases among workers who perform repetitive or forceful hand activity that can be
attributed to work range from 50 to 90% (Hagberg et al., 1992; Cummins, 1992; Tanaka et al., 1994).
With regard to epicondylitis, the individual roles played by force and repetition are less clear. One
cohort study and six cross-sectional studies have evaluated the incidence or prevalence of epicondylitis

Epidemiology of Upper Extremity Disorders

1-7

in relation to specific jobs, which were characterized by high force, high repetition, or both. Kurppa et
al. (1991) found a relative risk of 6.4 for epicondylitis in jobs with high repetition, some of which also
involved high force. One cross-sectional study found a significantly elevated risk of epicondylitis only
among recently employed workers in high-repetition or high-repetition/high-force jobs (Chiang et al.,
1993). Another cross-sectional study found an odds ratio of 6.9 epicondylitis in a high-repetition, highforce job (Roto and Kivi, 1984). This odds ratio was not statistically significant. Four other crosssectional studies found little or no increase in risk for epicondylitis in workers involved in jobs characterized
by high force and/or high repetition (McCormack et al., 1990; Luopajrvi et al., 1979).
Work involving increased wrist deviation from a neutral posture in either the extension, flexion or
ulnar, radial direction has been associated with carpal tunnel syndrome and other hand and wrist problems
(Thompson et al., 1951; Hoffman et al., 1981; Tichauer, 1966). De Krom et al. (1990) conducted a
case-control study of 156 subjects with carpal tunnel syndrome compared to 473 controls randomly
sampled from the hospital and population registers in a region of the Netherlands. After adjusting for
age and sex, a dose-response relationship was observed for increasing hours of work with the wrist in
extension or flexion. No risk was observed for increasing hours performing a pinch grasp or typing.
Some studies of computer operators have linked awkward wrist postures to severity of hand symptoms
(Faucett and Rempel, 1994), risk of tendinitis or carpal tunnel syndrome (Seligman et al., 1986), arm
and hand discomfort (Sauter et al., 1991; Duncan and Ferguson, 1974; Hunting et al., 1981).
Prolonged exposure to vibrating hand tools, such as chain saws, has been linked in prospective
studies to Hand Arm Vibration Syndrome (Ekenvall and Carlsson, 1987; Futatsuka and Ueno, 1986).
The risks are primarily vibration acceleration amplitude, frequency, hand coupling to tool, hours per
day of exposure, and years of exposure. However, based on existing studies, there is no clear vibration
acceleration/frequency/duration threshold that would protect most workers. Therefore, medical
surveillance is recommended to identify cases early while the disease can still be reversed (NIOSH,
1989). Use of vibrating hand tools may also increase the risk of CTS (Seppalainen, 1970; Cannon et al.,
1981) indirectly by increasing applied grip force through a reflex pathway (Radwin et al., 1987).
Prolonged or high-load localized mechanical stress over tendons or nerves from tools or resting the
hand on hard objects have been associated with tendinitis (Tichauer, 1966) and nerve entrapments
(Phalen, 1966; Hoffman and Hoffman, 1985) in case studies.
The average total hours per day that a task is repeated or sustained has been a factor in predicting hand
problems (Margolis, 1987; Macdonald, 1988). Among computer operators increasing self-reported hours
of computer use has been a predictor of symptom intensity or disorder rate in all (Faucett and Rempel,
1994; Burt et al., 1990; Bernard et al., 1993; Oxenburgh et al., 1985; Maeda et al., 1982; Hunting et al.,
1981). De Krom et al. (1990) did not observe a relationship between CTS and hours of computer use.
Work organizational (work structure, decision control, work load, deadline work, supervision) and
psychosocial factors (job satisfaction, social support, relationship with supervisor) appear to have some
influence on hand and wrist symptoms among computer users. Among newspaper reporters and editors,
work organizational factors modified the expected relationship between workstation design and hand
and wrist symptoms. Symptom intensity increased as keyboard height increased among those with low
decision latitude but not among those with high decision latitude (Faucett and Rempel, 1994). In another
study of newspaper employees, the risk of hand and wrist symptoms was increased among those with
increasing hours on deadline work and less support from the immediate supervisor (Bernard et al.,
1993). Among directory assistance operators at a telephone company, high information processing
demands were associated with an elevated rate of hand and wrist disorders (Hales et al., 1994). On the
other hand, in the industrial setting, Silverstein et al. (1986) observed no effect on job satisfaction.

1.5 Summary
The lack of prospective studies and an uncertainty about the precise pathophysiologic mechanisms
involved limits our ability to definitively identify causative factors. Nonetheless, current studies point to

1-8

Occupational Ergonomics: Engineering and Administrative Controls

a multifactorial relationship between work exposures and disorders of the hand, wrist, and elbow.
Symptom severity and disorder rate appear to be influenced by work organizational factors, such as
decision latitude and cognitive demands. Some disorders, such as tendinitis and carpal tunnel syndrome,
are clearly associated with work involving repetitive and forceful use of the hands. It seems likely that
there is a causal relationship between some work exposures and these disorders. For other disorders,
such as epicondylitis and osteoarthritis, the relationship to work exposures is less clear, although current
data are suggestive. Carpal tunnel syndrome has been linked to individual factors in population-based
studies and in clinical case series. However, in workplace studies where workplace exposures are adequately
quantified, individual factors play a limited role relative to workplace factors (Cannon et al., 1981;
Silverstein et al., 1987; Armstrong and Chaffin, 1979; Franklin et al., 1991; Faucett and Rempel, 1994;
Hales et al., 1994).

References
Adams ML, Franklin GM, Barnhart S. Outcome of carpal tunnel surgery in Washington State workers
compensation. Am J Ind Med 1994; 25:527536.
Al-Qattan MM, Bowen V, Manktelow RT. Factors associated with poor outcome following primary
carpal tunnel release in non-diabetic patients. J Hand Surg (Br Volume) 1994; 19B:622625.
Amadio PC. Pyridoxine as an adjunct in the treatment of carpal tunnel syndrome. J Hand Surg 1985;
10A:237241.
Armstrong TJ, Langolf GD. Ergonomics and occupational safety and health, in Environmental and
Occupational Medicine, ed WN Rom, Little, Brown Co, Boston, 1982, pp. 765784.
Armstrong TJ, Chaffin DB. Carpal tunnel syndrome and selected personal attributes. J Occup Med
1979; 21:481486.
Armstrong TJ, Foulke JA, Joseph BS, Goldstein SA. Investigation of cumulative trauma disorders in a
poultry processing plant. Am Ind Hygiene Assoc J 1982; (43)2:103116.
Armstrong TJ, Buckle P, Fine LJ et al. A conceptual model for work-related neck and upper-limb
musculoskeletal disorders. Scand J Work Environ Health 1993; 19:7384.
Bammer G. VDUs and musculoskeletal problems at the Australian National University, in Work with
Display Units 86, Eds Knave B and Wideback PG, Elsevier Science Publishers B.V. North-Holland,
1987.
Barnhart S, Demers PA, Miller M, Longstreth WE, Rosenstock L. Carpal tunnel syndrome among ski
manufacturing workers. Scand J Work Environ Health 1991; 17:4652.
Bernard B, Sauter S, Peterson M, Fine L, Hales T. Health Hazard Evaluation Report: Los Angeles Times.
U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control,
National Institute for Occupational Safety and Health, NIOSH Report No. 900132277. 1993.
Birkbeck MQ, Beer TC. Occupation in relation to the carpal tunnel syndrome. Rheumatol Rehabil
1975; 14:218221.
Bjorkqvist SE, Lang AH, Punnonen R, Rauramo L. Carpal tunnel syndrome in ovariectomized women.
Acta Obstet Gynecol Scand 1977; 56:127130.
Bleeker MQ, Bohlman M, Moreland R, Tipton A. Carpal tunnel syndrome: role of carpal canal size.
Neurology 1985; 35:15991604.
Burt S, Hornung R, Fine L, Silverstein B, Armstrong T. Health hazard evaluation report: Newsday. U.S.
Department of Health and Human Services, Public Health Service, Centers for Disease Control,
National Institute for Occupational Safety and Health, NIOSH Report No. 892502046. 1990.
Campbell, CS. Gamekeepers Thumb. Journal of Bone and Joint Surgery 1955; 37(B) 1:148149.
Cannon LJ, Bernacki EJ, Walter SD. Personal and occupational factors associated with carpal tunnel
syndrome. J Occup Med 1981; 23:255258.
Centers for Disease Control: Occupational disease surveillancecarpal tunnel syndrome. MMWR 1989;
38:485489.
Cheadle A, Franklin G, Wolfhagen C, Savarino J, Liu PY, Salley C, Weaver M. Factors influencing the

Epidemiology of Upper Extremity Disorders

1-9

duration of work-related disability: a population-based study of Washington State Workers

Compensation. Am J Pub Health 1994; 84:190196.
Chiang HC, Chen SS, Yu HS, Ko YC. The occurrence of carpal tunnel syndrome in frozen food factory
employees. Kaohsiung J Med Sci 1990; 6:7380.
Chiang HC, Ko YC, Chen SS, Yu HS, Wu TN, Chang PY. Prevalence of shoulder and upper-limb
disorders among workers in the fish-processing industry. Scand J Work Environ Health 1993; 19:126
131.
Conn HR. Tenosynovitis. Ohio State Med J 1931; 27:713716.
de Krom M, Kester A, Knipschild P, Spaans F. Risk factors for carpal tunnel syndrome. Am J Epi 1990,
132:11021110.
Duncan J, Ferguson D. Keyboard operating posture and symptoms in operating. Ergonomics 1974;
17:651662.
Ekenvall L, Carlsson A. Vibration white finger: a follow up study. Br J Ind Med 1987; 44:476478.
Ekman-Ordeberg G, Salgeback S, Ordeberg G. Carpal tunnel syndrome in pregnancy: A prospective
study. Acta Obstet Gynec Scand 1987; 66:233235.
Ellis J, Folkers K, Watanabe T et al. Clinical results of a cross-over treatment with pyridoxine and
placebo of the carpal tunnel syndrome. J CJlin Nutr 1979; 20462070.
Falck B and Aarnio P. Left-sided carpal tunnel syndrome in butchers. Scand J Work Environ Health
1983; 9:291297.
Faucett J and Rempel D. VDT-related musculoskeletal symptoms: Interactions between work posture
and psychosocial work factors. Am J Ind Med 1994; 26:597612.
Fine LJ, Silverstein BA, Armstrong TJ et al. Detection of cumulative trauma disorders of upper extremities
in the workplace. J Occup Med 1986; 28:674678.
Franklin GM, Haug J, Heyer N, Checkoway H, Peck N. Occupational carpal tunnel syndrome in
Washington State, 19841988. Am J Pub Health 1991, 81:741746.
Franzblau A, Werner R, Valle J, Johnston E. Workplace surveillance for carpal tunnel syndrome: a
comparison of methods. J Occup Rehab 1993; 3:114.
Franzblau A, Werner RA, Albers JW, Grant CL, Olinski D, Johnston E. Workplace surveillance for
carpal tunnel syndrome using hand diagrams. J Occup Rehab 1994; 4:185198.
Futatsuka M, Ueno T. A follow-up study of vibration-induced white finger due to chain-saw operation.
Scand J Work Environ Health 1986; 12:304306.
Hadler N, Gillings D, Imbus H et al. Hand structure and function in an industrial setting. Arthritis and
Rheum 1978, 21:210220.
Hagberg M, Morgenstern H, Kelsh M. Impact of occupations and job tasks on the prevalence of carpal
tunnel syndrome. Scand J Work Environ Health 1992; 18:337345.
Hales TR, Sauter SL, Peterson MR, Fine LJ, Putz-Anderson V, Schleifer LR, Ochs TT, Bernard BP.
Musculoskeletal disorders among visual display terminal users in a telecommunications company.
Ergonomics 1994; 10:16031621.
Heller L, Ring H, Costeff H, Solzi. Evaluation of Tinels and Phalens signs in diagnosis of carpal tunnel
syndrome. Eur Neurol 1986; 25:4042.
Hoffman J, Hoffman PL. Staple gun carpal tunnel syndrome. J Occup Med 1985; 27:848849.
Hnting W, Lubli T, Grandjean E. Postural and visual loads at VDT workplaces. Ergonomics 1981;
24:917931.
Johnson EW, Gatens T, Poindexter D, Bowers D. Wrist dimensions: correlation with median sensory
latencies. Arch Phys Med Rehab 1983; 64:556557.
Katz JN, Stirrat CR, Larson MG, Fossel AN, Eaton HM, Liang MH. A self-administered hand symptom
diagram for the diagnosis and epidemiologic study of carpal tunnel syndrome. J Rheumatol 1990;
3:114.
Katz JN, Larson MG, Fossel AH, Liang MH. Validation of a surveillance case definition of carpal tunnel
syndrome. Am J Public Health 1991; 81:189193.

1-10

Occupational Ergonomics: Engineering and Administrative Controls

Kaji H, Honma H, Usui M, Yasuno Y, Saito K. Hypothenar Hammer Syndrome in workers occupationally
exposed to vibrating tools. J Hand Surg (Br Volume) 1993; 18B:761766.
Kivi P. Rheumatic disorders of the upper limbs associated with repetitive occupational tasks in Finald in
19751979. Scand J Rheum 1984; 13:101107.
Kuorinka I, Koskinen P. Occupational rheumatic diseases and upper limb strain in manual jobs in a light
mechanical industry. Scand J Work Environ Health 1979, 5:3947.
Kuorinka I, Forcier L. (eds.) Work Related Musculoskeletal Disorders: A Reference Book for Prevention.
London: Taylor & Francis, 1995.
Kurppa K, Viikari-Juntura E, Kuosma E, Huuskonen M, Kivi P. Incidence of tenosynovitis or peritendinitis
and epicondylitis in a meat processing factory. Scand J Work Environ Health 1991; 17:3237.
Little JM, Ferguson DA. The incidence of Hypothenar Hammer Syndrome. Arch Surg 1972; 105:684
685.
Luopajrvi T, Kuorinka I, Virolainen M, Holmberg M. Prevalence of tenosynovitis and other injuries of
the upper extremities in repetitive work. Scand J Work Environ Health 1979. 5:4855.
Marras WS, Schoenmarklin RW. Wrist motions in industry. Ergonomics 1993; 36:341351.
Maeda K, Hunting W, Grandjean E. Factor analysis of localized fatigue complaints of accountingmachine operators. J Human Ergol 1982; 11:3743.
Magnusson M, Ortengren R. Investigation of optimal table height and surface angle in meatcutting.
Applied Ergonomics 1987; 18.2:146152.
Masear VR, Hayes JM, Hyde AG. An industrial cause of carpal tunnel syndrome. J Hand Surg 1986;
11A:222227.
McCormack RR Jr., Inman RD, Wells A, Berntsen C, Imbus HR. Prevalence of tendinitis and related
disorders of the upper extremity in a manufacturing workforce. J Rheumatol 1990; 17:958964.
Moore JS, Garg A. Upper extremity disorders in a pork processing plant: relationships between job risk
factors and morbidity. Am Ind Hyg Assoc J 1994, 55:703715.
Muffly-Elsey D, Flinn-Wagner S. Proposed screening tool for the detection of cumulative trauma disorders
of the upper extremity. J Hand Surg 1987, 12A:2(2), 931935.
Nathan PA, Keniston RC, Myers LD, Meadows KD. Obesity as a risk factor for slowing of sensory
conduction of the median nerve in industry. J Occup Med 1992; 34:379383.
Nathan PA, Meadows KD, Doyle LS. Occupation as a risk factor for impaired sensory conduction of the
median nerve at the carpal tunnel. J Hand Surg 1988; 13B:167170.
NIOSH Criteria for a recommended standard. Occupational exposure to hand-arm vibration. DDHS
Publication No. 89106. 1989. National Institute for Occupational Safety and Health. Cincinnati,
Ohio.
NIOSH National Occupational Research Agenda. DDHS Publication No. 961115. 1996. National
Institute for Occupational Safety and Health. Cincinnati, Ohio.
Newland, CC. Gamekeepers Thumb. Orthopedic Clinics of North America 1992; 23(1):4148.
Nilsson T, Burstrm L, Hagberg M. Risk assessment of vibration exposure and white fingers among
platers. Int Arch Occup Environ Health 1989; 61:473481.
Ohara H, Aoyama H, Itani T. Health hazards among cash register operators and the effects of improved
working conditions. J Human Ergology 1976; 5:3140.
Osorio AM, Ames RG, Jones JR, Rempel D, Castorina J, Estrin W, Thompson D. Carpal tunnel syndrome
among grocery store workers. Am J Ind Med 1994, 25:229245.
Oxenburgh M, Rowe S, Douglas D. Repetitive strain injury in keyboard operators. J Occup Health and
SafetyAustralia and New Zealand 1985; 1:106112.
Park CH, Wagener DK, Winn DM, Pierce JP. Health conditions among the currently employed: United
States, 1988. National Center for Health Statistics. Vital Health Stat 1993; 10(186).
Phalen GS. The carpal-tunnel syndrome. J Bone Joint Surg 1966; 48A:211228.
Punnett L, Robins JM, Wegmen DH, Keyserling WM. Soft tissue disorders in the upper limbs of female
garment workers. Scand J Work Environ Health 1985; 11:417425.

Epidemiology of Upper Extremity Disorders

1-11

Radwin RG, Armstrong TJ, Chaffin DB. Power hand tool vibration effects on grip exertions. Ergonomics
1987; 30:833855.
Rempel D, Punnet L, Epidemiology of wrist and hand disorders, in Musculoskeletal Disorders in the
Workplace: Principles and Practice, eds M Nordin et al., Mosby-Year Book, Inc., St. Louis, Missouri,
1997.
Roto P, Kivi P. Prevalence of epicondylitis and tenosynovitis among meatcutters. Scand J Work Environ
Health 1984; 10:203205.
Sauter SL, Schleifer LM, Knutson SJ. Work posture, workstation design, and musculoskeletal discomfort
in a VDT data entry task. Human Factors 1991; 33:151167.
Seligman P, Boiano J, Anderson C. Health Hazard Evaluation of the Minneapolis Police Department.
NIOSH HETA 844171745, 1986. U.S. Department of Commerce, NTIS, Springfield, Virginia.
Seppalainen AM. Nerve conduction in the vibration syndrome. Scand J Work Environ Health 1970;
7:8284.
Silverstein BA, Armstrong T, Longmate A, Woody D. Can in-plant exercise control musculoskeletal
symptoms? J Occup Med 1988; 30:922927.
Silverstein BA, Fine LJ, Armstrong TJ. Hand wrist cumulative trauma disorders in industry. Br J Ind
Med 1986. 43:779784.
Silverstein BA, Fine LJ, Armstrong TJ. Occupational factors and carpal tunnel syndrome. Am J Ind Med
1987. 11:343358.
Silverstein BA, Fine LJ, Stetson D. Hand-wrist disorders among investment casting plant workers. J
Haand Surg 1987; 12A (5 part 2):838844.
Stevens JC, Sun S, Beard CM, OFallon WM, Kurland LT. Carpal tunnel syndrome in Rochester,
Minnesota. 1961 to 1980. Neurology 1988; 38:134138.
Stock SR. Workplace ergonomic factors and the development of musculoskeletal disorders of the neck
and upper limbs: A meta-analysis. Am J Ind Med 1991; 19:87107.
Tanaka S, Wild DK, Seligman PJ, Behrens V, Cameron L, Putz-Anderson V. The U.S. prevalence of selfreported carpal tunnel syndrome. Am J Public Health 1994; 84:18461848.
Thompson A, Plewes L, Shaw E. Peritendinitis crepitans and simple tenosynovitis: a clinical study of
544 cases in industry. Br J Ind Med 1951; 8:150160.
Tichauer E. Some aspects of stress on forearm and hand in industry. J Occup Med 1966; 8:6371.
Viikari-Juntura E. Neck and upperlimb disorders among slaughterhouse workers. Scand J Work Environ
Health, 1983; 9:283290.
Vessy MP, Villard-MacIntosh L, Yeates D. Epidemiology of carpal tunnel syndrome in women of childbearing age. Finding in a large cohort study. Am J Epi 1990; 19:655659.
Webster BS, Snook SH. The cost of compensable upper extremity cumulative trauma disorders. J Occup
Med 1994; 36:7137.
Welch R. The causes of tenosynovitis in industry. Indust Med 1972; 41:1619.
Werner RA, Albers JW, Franzblau A, Armstrong TJ. The relationship between body mass index and the
diagnosis of carpal tunnel syndrome. Muscle & Nerve 1994; 17:632636.
Williams, Cope et al. Metacarpo-phalangeal arthropathy associated with manual labor (Missouri
metacarpal syndrome). Arthritis and Rheum 1987; 30:13621371.
Yamaguchi D, Liscomb P, Soule E. Carpal tunnel syndrome. Minn Med J 1965; January 2223.

2
Integrated Analysis of
Upper Extremity
Disorders
2.1 Introduction
2.2 Site and Types of Upper Limb Work-Related
Musculoskeletal Disorders
2.3 Risk Factors for Upper Limb Work-Related
Musculoskeletal Disorders

2-1
2-2
2-2

Time as an Integral Part of Risk Factor Description Posture

as a Risk Factor Force as a Risk Factor

2.4 Integrated Approach to Evaluate Potential for Upper

Limb WMSD

2-5

Approaches to Investigating Tendon Disorders Approaches

to Investigating Nerve Disorders Methodological
Approaches to Predicting Muscle Disorders in the Upper Limb

2.5 Workplace Assessment Tools

Richard Wells
University of Waterloo

2-9

Scope of Workplace Assessment Tools Reviewed

2.6 Summary

2-18

2.1 Introduction
Work and activity-related musculoskeletal disorders (WMSD) have a complex multifactorial etiology
including not only the physical aspects of the activities that people perform but also the psychosocial
aspects. These disorders may involve muscular, tendinous, ligamentous, nervous tissues and include
both acute (overexertion) as well as chronic (overuse) onset. A number of sources of information ranging
from biomechanics, epidemiology, and clinical case series have identified a number of major risk factors
associated with the development of upper limb musculoskeletal disorders. (For reviews, see Stock, 1992
or Hagberg et al., 1995.) These include forcefulness, adverse posture, repetition or continuous activity,
angular velocity and acceleration, or joints and duration of exposure. Plausible biological mechanisms
by which these risk factors may result in disorders of the musculoskeletal system have been proposed.
Despite this, our best evidence points to a complex interaction of physical, psychosocial, and individual
factors in the development of musculoskeletal disorders at work.
An integrated approach to the causation of WMSD helps us understand the many simultaneous and
interacting physical stressors which act on the upper limb during activity. These approaches help form a
bridge between the performance of work and the cellular and other descriptions of the degenerative/
inflammatory processes involved in work and activity-related musculoskeletal disorders. An integrated approach

0-8493-1800-9/03/$0.00+$1.50
2003 by CRC Press LLC

2-1

2-2

Occupational Ergonomics: Engineering and Administrative Controls

also guides us in the construction and evaluation of workplace assessment tools. In the sections which
follow, concepts important to the assessment of the risk factors of force and posture are reviewed prior
to analyzing the features of a number of assessment tools.

2.2 Site and Types of Upper Limb Work-Related Musculoskeletal

Disorders
Terminology describing work-related musculoskeletal disorders (WMSD) has become extremely
convoluted; for example, in the U.S., where the term of preference is cumulative trauma disorders (CTD),
disorders in visual display terminal (VDT) operators are called repetitive strain injuries (RSI). In this
chapter WMSD refers to all disorders of the musculoskeletal system (both upper extremity and low
back and limbs) both to specific tissue as well as nonspecific symptoms and syndromes where associations
with work have been found (cf. Hagberg et al., 1995).
An examination of Figure 2.1 reveals that a large number of types of tissues have been identified as
being affected by work: tendon, muscle, nerve, and joint. The disorders identified are found in a wide
variety of locations in the hand, forearm, arm, shoulder, and neck. How can we possibly devise methods
which will allow us to predict injury risk in such a wide variety of sites and tissues? Fortunately,
quantification of the external loads applied to the upper limb and its posture have been successful in
describing the differences between jobs and tasks with high versus low risks of developing WMSD.
Technically this is known as a low specificity of effect; a specific work factor can cause a number of
different musculoskeletal disorders in a number of anatomic sites (Hagberg et al., 1995). This is likely so
because increasing the external demand, in terms of increased force or frequency of exertion, increases
the demands on most of the tissues (internal) of the arm and shoulder. While this makes the development
of workplace assessment tools simpler, it makes it more difficult to examine causation and the mechanisms
of disorders.

2.3 Risk Factors for Upper Limb Work-Related

Musculoskeletal Disorders
Sources of information ranging from biomechanics, epidemiology and clinical case series have identified
a number of major extrinsic (external) risk factors associated with the development of upper limb
musculoskeletal disorders. These include forcefulness, adverse posture, repetition or continuous activity,
joint angular velocity and acceleration, and duration of exposure. In addition, there are a number of
potentiating factors which are commonly mentioned including, cold, vibration, and use of gloves (Hagberg
et al., 1995). The following sections explore some concepts useful in the quantification of time and
posture.

Time as an Integral Part of Risk Factor Description

The time or frequency characteristics of tasks have typically been described by the term repetitiveness.
Unfortunately, this word is so often used and overused as to make such terms as repetitive job and
highly repetitive almost meaningless. No clear definition of the term is usually offered, which compounds
the lack of clarity.
In general the word is used in three main ways. First, it is used as a qualitative term to describe both
the high frequency of actions as well as the sameness or monotony of the job. Second, it has been used
to describe fast manual work with little apparent rest between movements. Third, repetitive work can be
quantified by the number of parts, efforts, keystrokes or wrist movements/per unit time. Perhaps the
most widely used operational definition of repetitive is that of Silverstein and colleagues: work with a
cycle time of less than 30 seconds or having a repeated sub-cycle lasting more than 50% of the main

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FIGURE 2.1 Schematic of the upper limb showing examples of the sites and tissues potentially involved in work-and
activity-related musculoskeletal disorders: {T} = tendon-related disorders; {N} = nerve-related disorders; {M} = musclerelated disorders; {V} = vascular disorders.

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cycle was categorized as being highly repetitive (Silverstein et al., 1986). Marras and colleagues have
developed approaches to quantifying the time-varying nature of body motions using angular velocity
and acceleration of both the wrist and trunk which have also been shown to be related to risk of injury
(Marras and Schoenmarklin, 1993; Marras et al., 1993; Schoenmarklin et al., 1994).
It can be noted that many of these definitions rate the frequency of both motions and force generation;
in general, each risk factor has an associated time variation. In addition, the phrase, repetitive job,
ignores the various functions of the different parts of the body. For example, a keyboard data entry task is
thought of as repetitive; true, the fingers have a high frequency of movement; however, the forearms,
shoulders, and back have almost constant and unchanging (static) posture and muscle activity. Westgaard
and Winkel have argued that each risk factor should be described by its intensity, time variation, and its
duration (Westgaard and Winkel, 1994; Winkel and Mathiassen, 1994). Ideally, the time dimension should
allow the effects of different work organizations to be predicted: the effects of micropauses, of different
work/rest ratios, of different break schedules, of rotation and work enlargement. At this time our knowledge
does not permit us to deal with this important dimension at more than a rudimentary level. This argues for
research into better ways of characterizing the time-varying nature of the major risk factors.
In the assessment of injury risk, tools must account for one more aspect of time. The estimation of
risk factors which relate either to the highest demand or to some measure of cumulative or average
loading. Despite the common notion that WMSDs are related to the accumulated exposure over months
or years, i.e., cumulative trauma disorders, there are surprisingly few examples where cumulative exposureresponse relationships have been demonstrated; most associations found are between exposure intensity
and WMSD. For example, Stenlund et al. (1992) found relationships between the cumulative load lifted
and arthrosis of the acromioclavicular joint in the shoulder, and Kumar (1990) found that workers with
back pain had higher cumulative loads on the spine. In a similar manner, long periods in non-neutral
postures have been associated with back pain (Punnett et al., 1991). Relationships have also been found
for maximum loads; for example, one of the stronger predictors found by Marras et al. (1993) for low
back pain was from maximum hand load.

Posture as a Risk Factor

Postures of the limbs and trunk have a long history in characterizing tasks because, unlike many other
risk factors, they are often observable and quantifiable without instrumentation. Posture is an important
element of task analysis because it can be related to a number of injury mechanisms. In general, posture
can give information about four kinds of stressors on the musculoskeletal system. First, if a limb segment
is inclined with respect to the line of gravity a joint moment of force is required about the proximal end
with the necessity for muscular or ligamentous forces to support it. Second, a joint angle close to the end
range of motion (extreme posture) will load ligaments and may compress blood vessels and nerves.
Third, joint angles away from the joints optimal working range will change the geometry of the muscles
crossing the joint, possibly impairing the optimal functioning of joints or tendons around the joint.
Fourth and last, the change (or lack of change) in posture may be used to characterize the frequency
(repetitiveness) or the static nature of the task.

Posture as a Predictor of Joint Moment of Force

As the previous section illustrated, the joint moment of force gives important insights into tissue loads.
As body segments deviate from the vertical, the ever-present force of gravity acts on the mass of the body
segment: the hidden load of the arm mass about the shoulder and particularly the trunk mass about
the low back are important, especially in sedentary tasks where the posture may be maintained for
substantial periods of time. This is frequently termed postural load. If weights are held in the hand, a
moment is usually created by the load in non-neutral postures.

Extreme Posture as a Predictor of Soft Tissue Loads

Usually the extremes of a joints motion are constrained by ligaments: use of extreme posture during
work may not be desirable. For example, in the low back during stoop lifts, flexion of the lumbar

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spine creates tension in the posterior ligaments of the spine, and in many people a flexion relaxation
phenomenon is seen whereby the extensor muscles of the spine become inactive and the ligaments
support the moment (McGill and Norman, 1993). The drawback and potential risk in this for low back
injury is that if there are unexpected loads or slipping, the only structures which can support the extra
loads are the ligaments. If the posture is held for long periods of time, for example in steel reinforcement
workers or gardeners, creep of the spinal ligaments and a change in the stability of the spine may result.

Joint Posture and Optimal Musculoskeletal Geometry

For each joint there is a range of posture which minimizes possible adverse features of work and which
allows effective force application with minimum fatigue and injury potential. Even before an extreme
posture is reached, there are changes in the function of the musculoskeletal system which usually make
the postures less than optimal and which may elevate tissue loads.
For example, at the wrist, extension of greater than about 30 degrees increases intracarpal pressure,
even in normal people, above 30 mmHg (Rempel et al., 1995). This pressure, if maintained for substantial
periods of time, likely decreases microcirculation of the structures in the tunnel, including the median
nerve. This may be one of the mechanisms by which work activities cause carpal tunnel syndrome.
Another example at the wrist involves grasping a small object with the wrist in flexion. This can require
large effort, and forcing the wrist into maximal flexion will usually cause the object to be dropped. This
is the basis of a number of actions in self-defense. This example shows that nonoptimal postures require
higher efforts to perform a given task. Large deviation from approximately neutral postures can also
affect blood supply: looking upward, as during the picking of fruit, can compromise cerebral blood flow
especially if coupled with neck twist (Sakakibara et al., 1987).
Each joint has an optimal position for different work activities; it is often near the midpoint of the
range of motion, but this rule has sufficient exceptions to make it unreliable. For example, the knee
functions very well close to the extreme straight position during most locomotor tasks.

Change of Posture
Work involves changes in posture, and the changes can be used to quantify the frequency of movements.
Frequency of activity is described further in a later section. If postures do not change for long periods of
time, such as shoulder and trunk posture during computer (VDT) work, the task may be called static.

Force as a Risk Factor

Despite the existence of a large number of external risk factors (Figure 2.2), it can be argued that the
final common pathway by which work causes or contributes to the development of WMSD is force.
External loads and postures give rise to internal exposures in the tissues of the upper limb. Thus a
fingertip force may give rise to tensile force in the finger flexor tendons; simultaneous wrist flexion
stretches the wrist and finger extensors, increasing their passive tensile force (Keir et al., 1996); the wrist
flexion also increases the hydrostatic pressure in the carpal canal. These forces have a different effect on
each tissue which will be discussed in more detail shortly.
Externally we may wish to measure the force required or the force exerted by the hand (which may be
considerably more, depending on the friction and size of the object). We may wish to measure the
absolute force or the force relative to an individuals capacity.
It can be seen that posture is most frequently a modifier of or a predictor of the loads experienced by
the tissue. The foregoing shows why posture is such a valuable measure of workplace risks: only when
external loads are applied is it of limited use in workplace evaluation. The internal exposure to force,
however, remains central; other risk factors affect this directly or indirectly.

2.4 Integrated Approach to Evaluate Potential for Upper Limb WMSD

Figure 2.2 illustrates an integrated approach to evaluate the potential for upper limb WMSD: the
external factors of force, posture, time variation (repetitiveness), and duration of exposure act on the

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FIGURE 2.2 Illustration of the distinction between external exposures to the body and internal exposures to
individual tissues. Under each tissue some of the measures for evaluating the potential for developing work-related
musculoskeletal disorders are listed.

musculoskeletal system. These create internal exposures to the tissues of the body. It is these internal
exposures which stress the individual tissues and which must be resisted: it is at this level which injury
mechanisms can be tested using histological, physiological, or electrophysiological techniques. For
example, through the use of external forces (An et al., 1987) and limb accelerations (Marras and
Schoenmarklin, 1993) moments of force at the elbow during work can be predicted. Because the
musculoskeletal system is mechanically indeterminate, i.e., there are more force-producing structures
than equations of equilibrium to describe the system, analysis to predict the load in the individual tissues
demands either that assumptions be made concerning how muscles are recruited be made or some
criterion measure is minimized through optimization approaches (An et al., 1987; Wells et al., 1995). In
addition, through the incorporation of the biological materials properties the response of the tissue to
load can be grossly predicted. The models available to study activity-related musculoskeletal disorders
are in preliminary stages of development. This is complicated by the lack of a good animal model of
these disorders and the delicate balance of physical strain and restorative responses.
In general these internal exposures are the subject of laboratory-based research rather than workplace
assessment, but they are important because they help us conceptualize the best external variables to
measure and the best way in which to evaluate them. For example, in the depiction of manual material
handling tasks to elucidate the link between work and low back pain, one could describe the load lifted
by a person, and separately, the distance away from the body of this mass. It has been found more useful
to compute the joint moment; the product of the force and the distance (Marras et al., 1993). This is
done based on a biomechanical model which demonstrates that tissue loads (internal exposures) are
better reflected by moment than either load or posture separately. Similar arguments can be made at the
shoulder.
Figure 2.3 depicts a conceptual model of the factors influencing the development of work-related
carpal tunnel syndrome. The pathways indicated a way in which the multiple demands of work may
combine to reduce or elevate potential for trauma to the tissue. Take, for example, work in the cold with
a vibrating tool; gloves will also likely be worn. The diagram illustrates how the presence of gloves may
increase grip force; the presence of cold and vibration may decrease tactile sensation and further increase
grip force.

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FIGURE 2.3 Conceptual model of the relationship between external risk factors and the development of carpal
tunnel syndrome due to both compression of the median nerve by the flexor tendons and changes in carpal tunnel
geometry due to posture alone. Across the center are listed the major (external) risk factors of force, posture and
time. Below are listed risk factors which may elevate the effect of these primary factors, and above are noted possible
pathways by which the external exposures (risk factors) create internal exposures that could plausibly lead to the
development or aggravation of CTS. Many additional factors can alter the forces in the flexor tendons such as the
grip type, number of digits used, and the angular acceleration of the wrist. Lack of skill may lead to poorer postures,
higher grip forces, or increased coactivation of muscles, more movements to perform a given task, or jerkier (higher
acceleration) motions.

Building on this concept, Moore et al. (1991) described an integrated approach using biomechanical
modeling to predict internal exposure variables likely related to injury. This is achieved by the synthesis
of posture, force, movement, and muscle loading data. The model produced a profile of measures for
use in industrial settings, that reflect the loading on the different tissues affected by WMSD (nerves,
tendons, muscles) and the different loading mechanisms (e.g., highly static postures, repeated extreme
postures, dynamic movements). The measures involve continuous monitoring of hand/wrist postures,
forces, and muscle activations (electromyographic signals) over the duration of the task both in the arms
and shoulders. Using the previously described measures as input to a biomechanical model of the forearm
and hand, a profile of 12 risk factors was created which characterized the demand of the task on the
distal upper limb. The 12 variables were: peak tendon force, cumulative tendon force, cumulative tendon
excursion, peak tendon excursion velocity, average pressure on the flexor retinaculum (and thus the
median nerve), peak pressure on the flexor retinaculum, cumulative pressure on the flexor retinaculum,
cumulative frictional work on the flexor tendons, peak frictional power, and three measures of the
flexor myographic signal, the 10th or static, 50th, and 90th percentiles of the amplitude probability
distribution function (APDF).
The models above integrated information from anatomical, biomechanical, and epidemiological studies
to produce a profile of measures to characterize tasks and which reflected injury mechanisms for different
tissue types. These will now be briefly reviewed.

Approaches to Investigating Tendon Disorders

Etiologically, reduced lubrication between tendons and tendon sheaths due to excess relative movement
has been suggested in tenosynovitis (Rowe, 1987) while high peak loads and cumulative strain have been
suggested for tendinitis (Goldstein et al., 1987). Norman and Wells (1990) have proposed a model for
assessment of tenosynovitis which was operationalized by Moore et al. (1991). This is seen in Figure 2.4.

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FIGURE 2.4 Conceptual model of the relationship between external risk factors and the development of tenosynovitis.
Across the center are listed the major risk factors of force and posture. Below are listed risk factors which may
elevate the effect of these primary factors, and above are noted possible pathways by which the external exposures
(risk factors) create internal exposures that could plausibly lead to the development or aggravation of tenosynovitis.
Many additional factors can alter the forces in the flexor tendons, such as the grip type, number of digits used, and
the angular acceleration of the wrist. (Adapted from Norman, R.K. and Wells, R.P. 1990. Biomechanical aspects of
occupational injury, Proceedings of the 23rd Annual Conference of the Human Factors Association of Canada. With
permission.)

In this approach the frictional work done by the tendon sliding through its sheath is calculated. One
type of frictional work is present due to a belt-pulley interaction when the wrist deviates from a
straight position (Armstrong and Chaffin, 1979). In addition to this type of frictional work, it is suggested
that a non-negligible resistance to movement is present to move the tendons through the carpal tunnel
even in the straight position. Estimates from the work of Goldstein et al. (1987) and Smutz et al. (1995)
put this resistance at around 5N in the neutral position. Excursion of the tendons at the wrist (caused by
finger and wrist movement) in both deviated, and straight postures will therefore create an energy input,
possibly beyond the recovery capability of the tissue.

Approaches to Investigating Nerve Disorders

Insult to the median nerve, whether due to increased hydrostatic pressures in the carpal canal (Rempel et al.,
1995) or due to mechanical insult upon the nerve by overlying tendon (Keir and Wells, 1995), has often been
suggested as a likely mechanism of work-induced carpal tunnel syndrome. More controversially, it may be
caused by hypertrophy or edema of the synovial sheaths and thus be secondary to tenosynovitis.
Mechanical stress to the median nerve can be predicted by modified belt-pulley models of the wrist
and is an output of a biomechanical model (Moore et al., 1991). Hydrostatic pressures are measurable
using in vivo and in vitro techniques (Keir and Wells, 1995).

Methodological Approaches to Predicting Muscle Disorders in the Upper Limb

Recent clinical findings have suggested that forearm muscle pain may be an overlooked problem in
studying work-related chronic musculoskeletal injuries (Ranney et al., 1995). While work-related muscle

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pain is well accepted in the shoulder area (e.g., Veiersted et al., 1993), pain in the forearm is usually
attributed to tendinitis or epicondylitis. The major approach to investigating muscle-related occupational
disorders is electromyography. Jonsson (1982) described a technique in which the frequency of any
particular level of EMG occurring is calculated. From this, an amplitude probability curve is developed.
The static level describes the ability of the muscle to rest at least 10% of the time and appears important
in the development of chronic work-related muscle problems. If the value is greater than zero, the
muscle is not given a chance to completely rest at least 10% of the time during a task. While this is a
useful technique for quantifying muscle usage throughout the duration of a task, it gives no indication
of the duration of each rest pause, i.e., whether the rests came as numerous pauses or one big pause.
Veiersted et al. (1990, 1993) addressed this by using a gaps analysis. This analysis looks at the number
of times the muscle is turned off (an EMG gap is defined as a muscle activation of less than 0.5%
MVC lasting for more than 0.2 seconds), and it appeared that people with pain had fewer gaps. More
recently it has been shown that workers likely to require neck/shoulder sick leave can be predicted from
measures of gap frequency (Veiersted et al., 1993).

2.5 Workplace Assessment Tools

Scope of Workplace Assessment Tools Reviewed
The previous sections have described some of the main risk factors which increase the risk of developing
upper limb musculoskeletal disorders and how these risk factors may produce internal exposures to
tissues of the body potentially leading to premature fatigue or WMSD. It falls to this section to describe
and review some of the tools in the literature which have been developed to assess workplace risk of
WMSD. Tools included met two conditions: (1) the tool or method not only recorded risk factors but
rated them and (2) rated the injury risk to the upper limbs or the intervention priority.
The workplace assessment tools reviewed fell into two main categories: those using mainly
observational methods to identify, rate, and combine a number of risk factors to produce an estimate of
risk for upper limb musculoskeletal disorders (e.g., Strain Index) or intervention priority (e.g., RULA)
and which are often suggested as screening tools, and those which measured (sometimes called technical
methods) the time course of a more complex risk factor (e.g., the trapezius electromyogram) and produced
an estimate of risk. The tools are described in Table 2.1 and evaluated on a number of criteria which are
important either from a conceptual, measurement, or usability viewpoint. The following sections describe
these criteria.

Stated Purpose
The tools can only be reviewed on the basis of the stated purpose; this purpose differed between the
tools. For example, the RULA output is in terms of an intervention priority, whereas trapezius EMG has
been associated with neck/shoulder musculoskeletal sick leave. Some tools were designed for screening
purposes whereas others were intended to produce more definitive analyses. The precise area of the
body for which the tool predicts risk also differs between tools and methods; for example, RULA has
upper limb and trunk scores and defines an intervention priority based upon the combined whole body
score, whereas the Strain Index is specific to the distal upper limb.

Input Variables
As noted in the previous sections, there is a wide range of potential stressors for the upper limb; how
many there are and how they are measured is important information concerning the potential
generalizability of the method. The handling of the time-varying nature of the risk factors is, to this
author, of prime importance both for its usefulness and its ability to answer the frequently asked questions
concerning line balancing, job rotation, and break schedules. The inputs are described by the forces and
postures adopted, the characterization of their time course, as well as the treatment of other risk factors.

TABLE 2.1 Comparison of Workplace Assessment Tools in the Literature which Have Been Developed to Assess Workplace Risk of WMSD and Priority for Intervention

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TABLE 2.1 (continued) Comparison of Workplace Assessment Tools in the Literature which Have Been Developed to Assess Workplace Risk of WMSD and Priority for Intervention

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TABLE 2.1 (continued) Comparison of Workplace Assessment Tools in the Literature which Have Been Developed to Assess Workplace Risk of WMSD and Priority for Intervention

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The tools differed considerably in their treatment of the time course of the input variables; some used
only a single instant while others used mathematical or electronic processing to extract information
about the time variation of the risk factor.

Rating of Individual Risk Factors

As previously noted, only tools which evaluated the size of the risk factor(s) have been reviewed here;
how this is done and the quality of this assessment is key to the usefulness of the tool. It is difficult to
imagine any work without some risk factors present and one can quickly fall into the mindset that work
is inherently dangerous and the observation of a bent wrist during work implies hazard. A distinction is
made in industrial hygiene between toxicity and hazard. Benzene is highly toxic, yet if used infrequently
where the concentration is small (a persons exposure is low), the hazard is small. Similarly, even for
wrist flexion close to an individuals range of motion (ROM), the risk is also low if the motion is
infrequent. In fact the adoption of extreme postures for short periods of time is probably beneficial;
they are called stretch breaks.
A number of approaches are seen ranging from statistical treatments based on epidemiological studies
to expert and consensus judgments. For single risk factors epidemiological approaches are possible;
however, some element of expert judgment becomes necessary to fill-in the holes in the epidemiological
literature.

Combination of Risk Factors

Very few epidemiological studies allow the interactions of a number of risk factors to be examined. For
example, Silverstein and colleagues did study a simple 2 2 interaction of force and repetitiveness
(Silverstein et al., 1986), while the psychophysical approach allows combinations of multiple dimensions
to be rated. These studies are not common and so the majority of studies combine rating of the individual
risk factors with additive or multiplicative models to arrive at a risk estimate.
The combination of risk factors to produce an estimate of risk is perhaps the most difficult issue in
workplace evaluation and tool construction. Should the individual risk factor ratings be added or
multiplied or even considered completely separately? For example, in evaluating the risk of low back
pain on a job one could measure the risk factor of posture and load separately. Does one add the
posture and load score or multiply them? Biomechanical models indicate that multiplying the load
and its moment arm about the low back (in effect, posture) gives the low back moment of force (or
torque). This has been found to give the best single prediction of low back pain risk (Marras et al.,
1993). Clearly the integrated approach advocated here uses biological and mechanical arguments to
help in this decision.
In industrial hygiene exposure levels are considered separately except when the agent of interest has
the same target organ or pathway. For example, in a given job there is exposure to work overhead and
hand/arm vibration from a hand tool. Does this mean the job has two risk factors which need improvement
or is there more risk than if either of these exposures occurred separately? The first approach is supported
by different target organs, the shoulder and forearm, while the low specificity of effect (Hagberg et
al., 1995) could argue for the second interpretation.
Based on the discussion of the importance of time as a descriptor of risk factors, it would appear that
time must be considered along with the primary risk factor, force. In some cases both force and posture
are considered and in these cases, both force and posture may be considered with their time variation. In
some cases posture may be used as a surrogate of force and in such cases its time variation must be
considered. In all these cases, this may be done additively or, more commonly, multiplicatively (cf.
NIOSH, 1981; Moore and Garg, 1995).
Definitive answers to the above conceptual issues are not available, and so the magnitude of the total
score calculated and its relation to risk must be cautiously interpreted. In the case of tools whose purpose
is to calculate intervention priority, these questions are not as critical because the scores are used as a
summary of the size of the individual risk factors and their number combined.

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Equipment Required
The equipment required is important in the choice of a tool; some methods utilize observations of work,
while others use various technical methods, such as electromyography or goniometry, in the
measurement process. This obviously affects the time and cost of the assessment. While it is sometimes
heard that ergonomics assessments must be simple and cheap, the value of more costly yet precise
technical measures with epidemiologically determined relationships to risk must not be undervalued.
The time, training required, and cost of using the tools are rarely reported.

Measurement Characteristics
The tools developer can arrive at an estimate of risk in a large number of ways; what is important,
however, is the quality of the tools predictions. This can be assessed in terms of the measurement
characteristics and validity. The measurement characteristics refer to such qualities as intra-observer
reliability (or test-retest reliability) as well as inter-observer agreement or reliability. A tool with poor
reliability will be of limited usefulness. It may still, however, be able to distinguish jobs with many risk
factors and high risks from those with few risk factors and low risks, but it may not reliably distinguish
between jobs with less extreme contrasts. Good measurement characteristics become of even greater
concern if the tool is used for guidelines or legislative purposes.

Validity
The term validity can be used in a number of senses. Content validity refers to the completeness of the
assessment. Questions such as are all important risk factors rated are asked here. Most tools reviewed,
however, used some variant of criterion-related validity. The output of the tool was compared to some
health-related output on jobs or individuals. The stated purpose is important here in evaluating the
appropriate comparisons.

Study Base/Generalizability
It is not possible to test a tool under all possible conditions; the range of workplaces used to develop and
test the tool are useful in judging the applicability of the tool to a given target workplace. For example,
it is likely problematic to use a tool developed in an office environment to apply to a construction site.

Proposed Limit of Guideline Level?

Although not universal, many of the tools produced some recommendations or guidelines in terms of
the score or output of the tool. A number of tools have screening as their stated purpose. In this case a
two-(or more) step process is assumed, and those jobs exceeding some criterion score are further analyzed.
In this case a high sensitivity is desirable; a moderate number of false positive findings are accepted so
as not to miss potentially risky jobs in the first step.
For those tools whose purpose is to define risk, it is unreasonable to imagine that a single threshold
divides risky jobs from non-risky ones. Where the risk of developing various WMSDs has been produced
against a continuous exposure measure, it has been found that the risk increases steadily from the
nonexposed state, i.e., there is no obvious step or threshold evident (e.g., Punnett et al., 1991). The
threshold chosen is then dependent on the increased risk which is to be accepted (a societal judgment).
While a guideline value can be useful in the interpretation of an instruments score, the measurement
characteristics (the validity and the generalizability) of the tool must be of high quality before reliance
can be placed on these recommendations.

Information for Intervention

The assessment of risk is but one step in process of workplace improvement; a good tool provides
direction on which risk factors need addressing and also provides material and suggestions for solutions.
Ideally, it might also allow what if scenarios to be explored and predict what the level of risk will be
for the new combination of risk factors.

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Limitations
No tool is perfect; the limitations of a given tool need to be understood, however, so that undue reliance
on the output is not made where the tools predictions are likely not to be of high quality. Each tool
could have a large number of limitations; the focus of this section is on major areas where the predictive
power of the tool is suspect or untested.

2.6 Summary
This chapter has reviewed some concepts important in the measurement and evaluation of the major
risk factors for the development of WMSDs in the upper extremity. An integrative approach is followed
whereby anatomical, physiological, and biomechanical information is used to conceptualize upper limb
function and as a possible means to learn how work might cause WMSDs. These concepts are then used
to inform a review of some of the major upper limb workplace evaluation tools; each has different
purposes, strengths, and weaknesses. As these tools are further developed, the framework used in this
chapter should provide a springboard from which the reader can assess existing and new tools in the
light of their needs and available resources.

References
aras, A. 1987. Postural load and the development of musculo-skeletal illness: Scand. J. Rehab. Med;
Suppl. 18, 135.
aras, A. and Westgaard, R.H. 1987. Further studies of postural load and musculo-skeletal injuries of
workers at an electro-mechanical assembly plant. Applied Ergonomics; 18(3):211219.
An, K-N, Chao, E.Y., Cooney, W.P., and Lischeid, R.L. 1985. Forces in the normal and abnormal hand.
J. Orthop. Res.; 3:202211.
Armstrong, T.J., Castelli, W.A., Evans, F.G., and Diaz-Perez, R. 1984. Some histological changes in the
carpal tunnel contents and their biomechanical implications. J. Occup. Med; 26(3):197201.
Armstrong, T.J. and Chaffin, D.B. 1979. Some biomechanical aspects of the carpal tunnel. J. Biomechanics;
12:567570.
Goldstein, S.A. 1981. Biomechanical Aspects of Cumulative Trauma to Tendons and Tendon Sheaths.
PhD Thesis, University of Michigan.
Goldstein, S.A., Armstrong, T.J., Chaffin, D.B., and Matthews, L.S. 1987. Analysis of cumulative strain
in tendons and tendon sheaths. J. Biomechanics; 20(1):16.
Hagberg, M., Silverstein, B., Wells, R., Smith, R., Carayon, Hendrick, H.P., Perusse, M., Kourinka, I.,
and Forcier, L. (eds.). 1995. Work-Related Musculoskeletal Disorders (WMSD): A Handbook for
Prevention, Taylor & Francis, London.
Jonsson B. 1982. Measurement and evaluation of local muscular strain in the shoulder during constrained
work. J. Human Ergon., 11:7388.
Karhu, O., Kansi, P., and Kuorinka, I. 1977. Correcting working postures in industry: a practical method
for analysis. Applied Ergonomics; 8(4):199201.
Keir, R., Wells, R., and Ranney, D. 1996. Passive stiffness of the forearm musculature and functional
implications; A pilot study, in press. Clin. Biomech., 11(7):401409.
Keir, P.J. and Wells R. 1995. The effect of tendon loading and wrist posture on carpal tunnel pressure in
cadavers. Proceedings of the 19th Annual Meeting of the American Society of Biomechanics, Stanford
University, August 1, 1995, pp.129130.
Keyserling, W.M., Stetson, D.S., Silverstein, B.A., and Brouwer, M.L. 1993. A checklist for evaluating
ergonomic risk factors associated with upper extremity cumulative trauma disorders. Ergonomics;
36(7):807831.
Kumar, S., 1990. Cumulative load as a risk factor for low-back pain. Spine 15:13111316.

Integrated Analysis of Upper Extremity Disorders

2-19

Lifshitz, Y. and Armstrong, J. 1986. A design checklist for control and prediction of cumulative trauma
disorder in intensive manual jobs. Proceedings of the Human Factors Society, 30th Annual Meeting;
837841.
Larsson S.E., Bengtsson, A Bodegrd, L., Henriksson, K.G., and Larsson, J. 1988. Muscle changes in
work related chronic myalgia, Acta Orthop. Scand.; 59(5):5526.
Leskinen, T. and Tnnes, M. 1994. Utilization of a video-computer system for analyzing postural loadevaluation of observation. Proceedings of the 12th Triennial Congress of the International Ergonomics
Association, Toronto, Canada, August 15, 1994; Vol. 2 pp. 383385.
Marras, W.S. and Schoenmarklin, R.W. 1993. Wrist motions in industry. Ergonomics; 36(4):341
351.
Marras, W.S., Lavender, S.A., Leurgans, S.E., Rajulu, S.L., Allread, W.G., Fathallah, F.A., and Ferguson,
S.A. 1993. The role of dynamic three-dimensional trunk motion in occupational-related low back
disorders: the effects of workplace factors trunk position and trunk motion characteristics on risk of
injury. Spine; 18(5):61728.
Mattilla, M., Vilkki, M., and Tiilikainen, I. 1992. A computerized OWAS analysis of work postures in
the papermill industry, in: Mattila, M. and Karwowski, W. (eds.), Computer Applications in
Ergonomics, Occupational Safety and Health Elsevier, Amsterdam, 111.
Mathiassen, R. and Winkel, J. 1991. Quantifying variation in physical load using exposure-vs-time
data. Ergonomics; 34(12): 145568.
McGill, S.M. and Norman, R.W. 1992. Low back biomechanics in industry: the prevention of injury
through safer lifting, in Grabiner, M. (ed.), Current Issues in Biomechanics, Human Kinetics Publishers,
Champaign, 111, 69120.
McAtamney, L. and Corlett, E.N. 1993. RULA: a survey method for the investigation of work-related
upper limb disorders. Applied Ergonomics; 24(2):9199.
Moore, J.S. and Garg, A. 1995. The strain index: A proposed method to analyze jobs for risk of distal
upper extremity disorders. Am. Ind. Hyg. Assoc. J.; 56:443458.
Moore, A., Wells, R., and Ranney, D. 1991. Quantifying exposure in occupational manual tasks with
cumulative trauma disorder potential. Ergonomics; 34(12):14331453.
NIOSH 1981. Work Practices Guide for Manual Lifting, Cincinnati, OH: U.S. Department of Health
and Human Services. Technical Report No. 81122.
Norman, R.K. and Wells, R.P. 1990. Biomechanical aspects of occupational injury, Proceedings of the
23rd Annual Conference of the Human Factors Association of Canada.
Punnett, L., Robins, J.M., Keyserling, W.M., Herrin, G., and Chaffin, D.B. 1991. Back disorders and
non-neutral trunk postures of automobile assembly workers. Scand. J. Work Environ. Health,
17(5):337346.
Ranney, D., Wells, R., and Moore, A. 1995. Upper limb musculoskeletal disorders in highly repetitive
industries: precise anatomical physical findings. Ergonomics, 38(7):14081423.
Rempel, D. 1995. Musculoskeletal loading and carpal tunnel pressure, in Gordon, S., Blair, S., and Fine
L. (eds.), Repetitive Motion Disorders of the Upper Extremity, American Academy of Orthopedic
Surgeons, Rosemont Il, 123133.
Rowe M. 1987. The diagnosis of tendon and tendon sheath injuries: Sem. Occup. Med.; 2(1): 16.
Sakakibara, H., Miyao, M., Kondo, T., Yamada, S., Nakagawa, T., and Kobayashi, F. 1987. Relationship
between overhead work and complaints of pear and apple orchard workers. Ergonomics; 30(5):805
815.
Schoenmarklin, R.W, Marass, W.S., and Leurgans, S. 1994. Industrial wrist motions and incidence of
hand/wrist cumulative trauma disorders, Ergonomics; 37(9): 14491460.
Silverstein, B.A, Fine, L.J., and Armstrong, T.J. 1986. Hand wrist cumulative trauma disorders in industry.
Br. J. Ind. Med.; 43:779784.
Skie, M., Zeiss, J., Ebraheim, N.A., and Jackson, W.T. 1990. Carpal tunnel changes and median nerve
compression during wrist flexion and extension seen by magnetic resonance imaging. J. Hand Surg.;
15-A(6):934939.

2-20

Occupational Ergonomics: Engineering and Administrative Controls

Smutz, W.P, Bishop, A., Niblock, H., and Drexler, M. 1995. Measurement of creep strain in flexor
tendons during low-force, high-frequency activities such as computer keyboard use. Clin. Biomech.;
10(2):6772.
Snook, S., 1978. The design of manual materials handling tasks. Ergonomics; 21:963985.
Snook, S., Vaillancourt, D.R., Ciriello, V.M., and Webster, B.S. 1995. Psychophysical studies of repetitive
wrist flexion and extension. Ergonomics; 38(7):14881507.
Stenlund, B., Goldie, I., Hagberg, M., Hogstedt, C., and Marions, O., 1992, Radiographic osteoarthrosis
in the acromioclavicular joint resulting from manual work or exposure to vibration. Br. J. Ind.
Med.; 49:588593.
Stock, S.R., 1991, Workplace ergonomic factors and the development of musculoskeletal disorders of
the neck and upper limbs: A meta-analysis, Am. J. Ind. Med., 19:87107.
Veiersted, K., Westgaard, R., and Andersen, P. 1990. Pattern of muscle activity during stereotyped work
and its relation to muscle pain. Int. Arch. Occup. Environ. Health, 62:3141.
Veiersted, K.B., Westgaard, R.H., and Andersen, P. 1993. Electromyographic evaluation of muscular
work pattern as a predictor of trapezius myalgia. Scand. J. Work Environ. Health; 19:284290.
Veiersted, K.B. 1996. Reliability of myoelectric trapezius muscle activity in repetitive light work.
Ergonomics; 39(5):797807.
Wells, R., Ranney, D., and Keir, P. 1994. Passive force length properties of cadaveric human forearm
musculature, in Advances in the Biomechanics of the Hand and Wrist. Schuind, F., An, K-N., Cooney,
W.P., and Garcia-Elias, M. (eds.), Kluwer, Dordrecht, pp. 3140.
Wells, R., Keir, P.J., and Moore, A.E, 1995. Applications of biomechanical hand and wrist models to
work-related musculoskeletal disorders of the upper extremity, in Gordon, S.L., Blair, S.J., and Fine,
L.J. (eds.) Repetitive Motion Disorders of the Upper Extremity, American Academy of Orthopaedic
Surgeons, Rosemount, IL.
Winkel, J. and Westgaard, R., 1992. Occupational and individual risk factors for shoulder-neck
complaints, part II: the scientific basis (literature review) for the guide. Int. J. Ind. Erg.; 10:85104.
Winkel, J and Mathiasen, S-E. 1994. Assessment of physical work load in epidemiologic studies, concepts,
issues and operational considerations. Ergonomics; 37:979988.

3
Biomechanical Aspects
of CTDs
3.1 Introduction
3.2 Anatomy of the Upper Extremity

3-1
3-1

Skeletal System Muscular System Connective Tissue

and Carpal Tunnel Nervous System

3.3 Work-Related Muscle Disorders

3.4 Biomechanical Aspects of Muscle-Tendon
Disorders
3.5 Work-Related CTDs Involving the
Muscle-Tendon Unit

3-9
3-11
3-17

Tendinitis Lateral Epicondylitis

(Tennis Elbow) Supraspinatus Tendinitis
(Rotator Cuff Syndrome) Tenosynovitis
DeQuervains Tenosynovitis Trigger Finger

3.6 Biomechanical Aspects of Nerve Compression

Disorders
3.7 Work-Related CTDs Involving the Nerve
Richard [Link]
Marquette University

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Carpal Tunnel Syndrome Occupational Sources of Median

Nerve Compression in CTS Thoracic Outlet Syndrome

3.8 Summary

3-31

3.1 Introduction
The purpose of this chapter is to explain the biomechanical etiology of cumulative trauma disorders
(CTDs) that affect the hand, wrist, elbow, and shoulder. The assumption that these CTDs are caused, in
part, by work-related activity is based on biomechanical mechanisms that are consistent with
epidemiological findings. CTDs affect the soft tissues in the body, namely tendons, ligaments, muscles,
and nerves, and in general not bone tissue. Although some authors include bone tissue within the umbrella
of CTDs (Kuorinka and Forcier, 1995), this chapter will focus only on those CTDs affecting soft tissue.
A brief description of the anatomy of the upper extremity will be provided to familiarize the reader with
anatomical terms. Then the three major classes of CTDs, namely those involving muscle, the muscletendon unit, and nerve compression, will be discussed.

3.2 Anatomy of the Upper Extremity

Skeletal System
The bones of the upper extremity, which are illustrated in Figure 3.1, are of two types, long and short
bones. The long bones connecting the shoulder to the elbow (humerus), the elbow to the wrist (radius

0-8493-1800-9/03/$0.00+$1.50
2003 by CRC Press LLC

3-1

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Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 3.1 The long and short bones of the right upper extremity. (From Basmajian, J.V. 1982. Primary Anatomy,
8th edition, p. 57, Williams and Wilkins, Inc. With permission.)

and ulna), and the wrist to the fingers (metacarpals and phalanges) are adapted for weight bearing and
for sweeping, speedy movements that allow the hand to move in space and grasp and touch objects
(Rasch, 1989). The movement of the radius (thumb side) around the ulna (little finger side) in the
forearm permits the hand to be turned up (supination) or down (pronation), as illustrated in Figure 3.2.
The proximal and distal parts of the long bones display flared ends that act as attachment points for
other bones and for connective tissue, such as tendons and ligaments.
The cluster of small cubical bones comprising the wrist are the eight carpal bones, which are categorized
as short bones (Rasch, 1989). The carpal bones move with respect to each other to flex (palm side) and
extend (back side of hand) the wrist joint, while also allowing the wrist to move side to side, from a neutral
position to radial deviation (thumb side) and to ulnar deviation (little finger side), as shown in Figure 3.3.

Muscular System
The muscles of the body are the generators of internal force that convert energy chemically stored in the
body into mechanical work (Rasch, 1989). Skeletal muscle, also called striated muscle, is composed of
longitudinal fibers that follow the direction in which a muscle exerts a force, as seen in Figure 3.4. A
muscle is like a rope in that it can only pull or exert a force in tension, and it cannot push or exert a
weight-bearing force (compression force). As shown in Figure 3.5, a muscle exerts a tensile force by
contracting its thread-like fibers, which shortens the length of the muscle and in fusiform muscles creates
a bulge at its center.

Biomechanical Aspects of CTDs

3-3

FIGURE 3.2 The forearm in a pronated and supinated posture. (From Marklin, R.W. original artwork. With
permission.)

FIGURE 3.3 Postures of the wrist in the flexion-extension and radial-ulnar planes. (From Putz-Anderson, V. 1988.
Cumulative Trauma Disorders: A Manual for Musculoskeletal Diseases of the Upper Limbs, p. 54, Taylor & Francis.
With permission.)

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Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 3.4 A photograph of the left shoulder muscles from a cadaver, as seen from the side. (From McMinn,
R.M.H. and Hutchings, R.T. 1977. Color Atlas of Human Anatomy, p. 113, Year Book Medical Publishers, Inc.,
Chicago, IL. With permission.)

FIGURE 3.5 The shortening of a muscle as it contracts, generating a pulling force. (From Basmajian, J.V. 1982.
Primary Anatomy, 8th edition, p. 113, Williams and Wilkins, Inc. With permission.)

The muscles that flex and extend the elbow, which are shown in Figure 3.6, are the biceps and
triceps. The group of muscles that flex and extend the wrist are the forearm flexors and extensors, as
shown in Figure 3.7. The flexors and extensors located on the thumb side of the forearm also radially
deviate the wrist; likewise, the forearm flexors and extensors on the little finger side of the forearm
ulnarly deviate the wrist. The muscles in the forearm, which are the primary generators of hand pinch
and grasp forces, are called extrinsic muscles, while the much smaller muscles located within the hand
are called intrinsic muscles. One of the main functions of the intrinsic muscles in the hand is to cooperate
with the extrinsic muscles to generate hand movements that require dexterity and fine motor control.

Biomechanical Aspects of CTDs

A) Front of Right Arm

3-5

B) Back of Right Arm

FIGURE 3.6 The muscles that flex (a) and extend (b) the elbow. Figures (a) and (b) are the front and back views of
the right arm, respectively. (From Van de Graaff, K.M. and Rhees, R.W. 1987. Human Anatomy and Physiology, p.
107, Schaums Outline Series, McGraw-Hill Book Co. With permission.)

Connective Tissue and Carpal Tunnel

As shown in Figure 3.7, the extrinsic muscles of the forearm are attached to the fingers with strong cordlike collagen structures called tendons. The tendons attached to the flexor and extensor forearm muscles
are constrained within the wrist area by thick bands called the flexor retinaculum and extensor retinaculum,
as illustrated in Figure 3.8. The flexor and extensor retinacula are ligaments that attach carpal bones on
one side of the wrist to bones on the other side. The flexor retinaculum and carpal bones form a canal
called the carpal tunnel, through which nine tendons from the forearm flexor muscles and the median
nerve pass, as shown in Figure 3.8. As the flexor tendons course through the carpal tunnel on their way to
the fingers, they travel through a network of synovial sheaths, as shown in Figures 3.9 and 3.10. These
sheaths reduce the friction between the tendons and their adjacent structures as they wrap around tendons
in articulating joints of the wrist and fingers. The structure of a synovial sheath is an elongated and doublewalled bursa that contains synovial fluid, as illustrated in Figures 3.11 and 3.12. The inner wall of the
sheath is attached to the tendon, and the outer wall is attached to a fibrous sheath moored to a bone or
ligament. The inside surfaces of the sheaths inner and outer walls are lined with synovial fluid, which acts
as a lubricant as the tendon traverses inside the tunnel formed by the fibrous sheath.

Nervous System
The primary purposes of the peripheral nervous system (PNS), which serves voluntary skeletal muscles
of the extremities, head, neck, and torso, are first, to receive sensory information from outlying parts of
the body and relay this information to the central nervous system (CNS), which consists of the brain and
spinal cord. The second major purpose of the peripheral nervous system is to send motor signals that
activate muscles in the outlying area(s) in response to the sensory input. Of the several nerves traveling
through the arm, the nerve most often associated with CTDs is the median nerve. As shown in Figure

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Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 3.7 The muscles that flex (a) and extend (b) the wrist. Figures (a) and (b) are the front and rear views of the
right arm, respectively. (From Van de Graaff, K.M. and Rhees, R.W. 1987. Human Anatomy and Physiology, p. 109,
Schaums Outline Series, McGraw-Hill Book Co. With permission.)

FIGURE 3.8 Cross-sectional anatomy of the wrist. The area highlighted is the carpal tunnel. (From Chaffin, D.B.
and Andersson, G.B.J. 1991. Occupational Biomechanics, 2nd edition, p. 240, John Wiley & Sons Publishers. With
permission.)

Biomechanical Aspects of CTDs

3-7

FIGURE 3.9 The system of synovial sheaths that lubricate the flexor tendons as they bend around the wrist and
finger joints (palmar view of the right hand). (From Basmajian, J.V. 1982. Primary Anatomy, 8th edition, p. 158,
Williams and Wilkins, Inc. With permission.)

FIGURE 3.10 A magnified end view of a muscle, tendon, sheath, and bony attachment point. (From Putz-Anderson,
V. 1988. Cumulative Trauma Disorders: A Manual for Musculoskeletal Diseases of the Upper Limbs, p. 12, Taylor
& Francis. With permission.)

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Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 3.11 Structure of a synovial sheath. An area of the sheath has been cutaway to expose its double-walled
structure. Synovial fluid lines the inside of the sheaths inner and outer walls and reduces friction as the tendon
moves within its tunnel. Note: normally the tendon fits snugly in its tunnel, but is shown having a loose fit in this
figure for illustration purposes. (From Basmajian, J.V. 1982. Primary Anatomy, 8th edition, p. 119, Williams and
Wilkins, Inc. With permission.)

FIGURE 3.12 A bursa, which is a collapsed bag of connective tissue filled with synovial fluid, forms whenever a
tendon rubs against a hard structure, such as a bone. (From Basmajian, J.V. 1982. Primary Anatomy, 8th edition, p.
118, Williams and Wilkins, Inc. With permission.)

3.13a, the median nerve starts at the shoulder, provides motor inputs to muscles in the forearm and
thumb region, and provides sensory feedback from the palm region and from the thumb to the center of
the ring finger. The median nerve is the nerve of precision because it supplies motor function to the
extrinsic muscles in the forearm that flex the fingers and the intrinsic muscles in the thumb that exert a
precision grip (Feldman et al., 1983). Figure 3.14 indicates the sensory regions of the hand served by the
median nerve and the radial and ulnar nerves, which travel down the radial and ulnar sides of the
forearm, respectively, as illustrated in Figures 3.13b and 3.13c. The radial nerve is the nerve of stability
because it innervates the forearm extensor muscles that oppose and stabilize the precision and power
muscles on the forearms flexor side. The ulnar nerve is the nerve of power because it innervates the
muscles that provide wrist flexor power, but little precision (Feldman et al., 1983).

Biomechanical Aspects of CTDs

3-9

FIGURE 3.13 a) Front view of the paths of the median nerve as it travels down the right upper extremity. b) Rear
view of the paths of the radial nerve. c) Front view of the paths of the ulnar nerve. (From Basmajian, J.V. 1982.
Primary Anatomy, 8th edition, p. 340, Williams and Wilkins, Inc. With permission.)

3.3 Work-Related Muscle Disorders

After frequent or prolonged contractions, a muscle can feel painful for a relatively short period of time
and recover to full function, or it could develop a more serious chronic condition. If the pain disappears
after a relatively short period of time, the cause was probably temporary fatigue of the muscular tissues.
However, if the pain persists, the worker could have developed a muscle CTD.
The medical term describing muscle pain is myalgia, which includes a few specific muscle pain syndromes.
Myalgia can occur after vigorous or unaccustomed exercise, and also from work-related activity. A worker
can develop a myopathy called myofascial syndrome, which is characterized by the presence of one or
more discrete areas (or trigger points) that are tender and hypersensitive and from which pain may radiate
when pressure is applied (Kuorinka and Forcier, 1995, p. 81). Myofascial syndrome could be associated
with work-related activity, and a common work-related myofascial syndrome is tension neck syndrome
(also called shoulder-neck myofascial syndrome). Tension neck syndrome is a myofascial syndrome localized

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Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 3.13 (continued)

FIGURE 3.14 Sensory regions of the right hand served by the median, radial, and ulnar nerves. (From Basmajian,
J.V. 1982. Primary Anatomy, 8th edition, p. 341, Williams and Wilkins, Inc. With permission.)

Biomechanical Aspects of CTDs

3-11

FIGURE 3.15 A typical stress-strain curve of a tendon. (From Abrahams, M. 1967. Mechanical analysis of tendon
in vitro: A preliminary report, Med Biol Eng, Vol. 5, p. 435. With permission.)

in the shoulder and neck region with tenderness descending into the trapezius muscle. Occupational
groups cited in the literature that have been associated with high rates of tension neck syndrome are
those requiring repetitive arm movements and constrained postures (Kuorinka and Forcier, 1995).
The pathogenesis of myofascial syndromes is unknown; however, several hypotheses have been offered
in the literature, which include a lower capillary-to-fiber ratio for the slow twitch fibers (Type I), severe
depletion of ATP in the muscle, and dysfunctional energy metabolism (Kuorinka and Forcier, 1995). For a
more thorough discussion of muscle CTDs, the reader is referred to Kuorinkas and Forciers (1995) book,
which has a comprehensive description and discussion of biomechanical mechanisms of muscle CTDs.

3.4 Biomechanical Aspects of Muscle-Tendon Disorders

As a muscle shortens during contraction and lengthens during stretching, its tendon acts like a rope and
transmits the muscle force to the bony attachment site. As a tendon moves with a muscle, the length of the
tendon does not necessarily stay constant. A tendon has elastic properties and is analogous to a rubber
band. The muscle force applied to the tendon is a tensile force, which is commonly converted to the units
of stress (force divided by cross-sectional area of tendon). As the tensile force increases, the tendon elongates,
which is measured by strain (the percentage of change in length). Figure 3.15 shows a typical stress-strain
curve of a tendon with its three characteristic regions (Abrahams, 1967). In Region 1, the crumpled collagen
fibers of a relaxed tendon merely straighten under negligible loads. Then, as the tensile force increases, the
tendon passes through the toe region (region 2), and then has a linear relationship between stress and
strain in region 3. Although the tendon can elongate up to 5% strain before onset of failure, normal
tendon strain is below 3% (Abrahams, 1967; Elliott, 1965; Rigby et al., 1959).
The loading and unloading of a tendon can change its elastic properties depending on whether the
tensile force is increasing or decreasing. As shown in Figure 3.16, the amount of stress required to
elongate a tendon to a specific strain level is greater when a tendon is loaded (increase in tensile load)
then when it is unloaded (decrease in tensile load). This change in stress-strain curve is called hysteresis,
which results from a loss of energy, probably as heat, during the unloading phase (Moore, 1992).
Several CTDs reported in the literature occur at sites where a tendon wraps around a deviated joint.
As a muscle contracts and moves its tendon accordingly, the tendon can rub against its adjacent surface,

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Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 3.16 The stress-stress curve of a tendon depends on whether the tensile force is increasing or decreasing.
The difference in the stress-strain curves is called hysteresis. The units of stress and strain are N/mm2 and % elongation,
respectively. (From Moore, J.S. 1992. Function, structure, and responses of components of the muscle-tendon unit,
in State of the Art Reviews in Occupational Medicine, Vol. 7, No. 4, p. 721. With permission.)

usually a bone or ligament, as a rope rubs against a nonrotating pulley. Likewise, when the muscle
lengthens, the tendon moves in the opposite direction against its adjacent structures. In the wrist area,
the repetitive rubbing of the tendons against the carpal bones and flexor retinaculum can cause CTDs
known as tendinitis and tenosynovitis, which are inflammation of the tendon and its sheath, respectively.
Based on Landsmeers (1962) model, Armstrong and Chaffin (1979) developed a static model of a
tendon wrapping around a joint. Figure 3.17 depicts Landsmeers model of a tendon, which is analogous
to a rope bent around a nonrotating pulley, and Figure 3.18 illustrates the Armstrong and Chaffin
(1979) model as a reasonable representation of Landsmeers model. When the wrist is flexed, the flexor
tendons bend around the flexor retinaculum that is assumed to have a constant radius. When the wrist
is extended, the flexor tendons are supported on the dorsal side by the carpal bones that are assumed to
have a constant radius. Armstrong and Chaffin (1978) found that the radius in a flexed posture is larger
than in an extended posture.
The arc length of the tendon wrapping around the pulley is defined in Equation (3.1).
(3.1)
where
X = tendon arc length around pulley (mm)
R = radius of curvature of supporting tissues (mm)
G = angle of deviation of wrist from neutral (in radians)
The reaction forces acting normal to the tendon are shown in Figure 3.18 and defined in Equation (3.2).
(3.2)
where
Fn = normal supporting force per unit of arc length (N/mm)
Ft = average tendon force in tension (N)

Biomechanical Aspects of CTDs

3-13

FIGURE 3.17 Landsmeers (1962) model of a tendon wrapping around a joint. (From Chao, Y.S., An, K.N., Cooney,
W.P, and Linscheid, R.L. 1982. Biomechanics of the Hand: A Basic Research Study, p. 15, Biomechanics Laboratory,
Department of Orthopaedic Surgery, Mayo Clinic/Mayo Foundation, Rochester, MN. With permission.)

= coefficient of friction between tendon and supporting synovia

G = wrist deviation angle (radians)
R = radius of curvature of supporting tissues (mm)
Since is considered small (approximately 0.0032 [Fung, 1981]), it can be approximated by zero. This
changes Equation (3.2) to Equation (3.3).
Fn = Ft/R

(3.3)

Equation (3) reveals Fn is a function of the tendon force and radius of curvature. As the radius of
curvature decreases, the normal supporting force per unit of arc length increases. The normal supporting
force for women would be greater than for men because women have smaller wrists. Also, as the tendon
force increases, the normal supporting force increases.
The total supporting force Fr in Figure 3.18 is the force of the ligaments, bones, and median nerve in
the carpal tunnel acting on the flexor tendons. Fr is defined in Equation (3.4).
(3.4)
where
Fr = resultant force exerted by adjacent wrist structures on the flexor tendons (N)
Ft = tendon force (N)
G = wrist deviation angle (in radians)
Equation (4) indicates that Fr is a function of the tendon force and wrist deviation angle, but is independent
of radius of curvature. Figure 3.19 illustrates this relationship in that as the tendon force and wrist angle
increase, the resultant force Fr increases linearly.
The significance of Fn and Fr is based on the theory that increased normal forces place greater stress
on the tendon and its surrounding structures. The increase in normal force could cause the tendon and
its sheath or the fibrous sheath moored to bone or ligament to hypertrophy or inflame. If these structures

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Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 3.18 Armstrongs and Chaffins (1979) biomechanical model of a flexor tendon wrapping around the
flexor retinaculum. Ft is the tendon force, and Fr is the resultant reaction force exerted against the tendon. (From
Chaffin, D.B. and Andersson, G.B.J. 1991. Occupational Biomechanics, 2nd edition, p. 243, John Wiley & Sons
Publishers. With permission.)

were to hypertrophy or inflame, then the coefficient of friction ( in Equation (3.2)) would increase,
thereby placing even greater Fn on the tendons.
Dynamic movements that accelerate and decelerate the tendons around a nonrotating pulley could
exacerbate the trauma imposed on the tendons. Schoenmarklin and Marras (1990) developed a dynamic
model of a flexor tendon bent around the carpal bones or flexor retinaculum, taking into account the
acceleration and deceleration of a tendons movements. This model analyzes the effects of peak angular
acceleration on the resultant reaction force that the wrist bones and ligaments exert on tendons and
their sheaths in the flexion/extension plane. Like the Landsmeer (1962) and Armstrong and Chaffin
(1979) models, Schoenmarklin and Marras (1990) model the tendon as a rope bent around a fixed
pulley.
The quantitative effects of the wrists peak angular acceleration on resultant reaction forces were
based on the free body diagram (FBD) and massacceleration diagram (MAD) approach in engineering
dynamics (Meriam and Kraige, 1986). Figure 3.20 illustrates the FBD and MAD approach applied to a
wrist and hand in midposition (neither pronated or supinated). There is no externally applied load in
the hand. The hand is rotated in the horizontal plane around a vertical z axis, so the effects of gravity do
not play a role in this example. All the flexor tendons are grouped together as one tendon force vector
in order to maintain static determinacy. The hand is assumed to accelerate from a stationary posture, so
the angular velocity is theoretically zero, resulting in zero centripetal force.

Biomechanical Aspects of CTDs

3-15

FIGURE 3.19 The resultant reaction force (Fr), as modeled by Armstrong and Chaffin (1979), that is exerted against
the flexor tendons as a function of wrist angle and tendon force. (From Chaffin, D.B. and Andersson, G.B.J. 1991.
Occupational Biomechanics, 2nd edition, p. 247, John Wiley & Sons Publishers. With permission.)

The maximum tendon force (Ft-max) was computed as a function of five peak angular accelerations
(? = 3000, 6000, 9000, 12000, and 15000/sec2). Based on empirical data from normal subjects,
15000/sec2 was found to be about 50% of peak wrist acceleration in the flexion/extension plane
(Schoenmarklin and Marras, 1993). The Ft-max isdepicted in Figure 3.21 and is derived from Equation
(3.5) (LeVeau, 1977).
(3.5)
where
Ft-max = maximum force in flexor tendons, which is the force that the extrinsic flexor muscles in the
forearm exert on their tendons (N)
Ft-min = minimum force in flexor tendons, which is the force that the flexor tendons transmit to the
hand and fingers (N)
= coefficient of friction between tendons and their sheaths
G = wrist deviation angle (radians)
Since the coefficient of friction for human synovial joints bones is estimated to be very low (0.0032
according to Fung, 1981), then the calculation of the Ft-max force is very close to Ft-min. The Fr depicted
in Figure 3.21 and expressed in Equation (3.4) was calculated as the resultant force necessary to resist
Ft-max and Ft-min.

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FIGURE 3.20 The free body diagram (FBD) and mass acceleration diagram (MAD) approach used by Schoenmarklin
and Marras (1990) to calculate the peak reaction force (Fr in Figures 3.21 and 3.22) on the wrist when the wrist is
accelerated (in the flexion direction) at an extension angle of ?. (From Schoenmarklin, R.W. and Marras, W.S. 1990.
In Proceedings of the 34th Meeting of the Human Factors Society, p. 807. With permission.)

As shown in Figure 3.22, Fr increases approximately linearly as wrist angle or angular acceleration
increases, resulting in a curved plane that signifies an interactive effect between wrist angle and angular
acceleration. The greatest Fr occurs when the wrist is accelerated at a deviated wrist posture. The large
peak reaction forces exerted on the flexor tendons and their sheaths are due solely to wrist motion
without any externally applied load in the hand. If loads were applied in the hand (e.g., power grip or
pinch grip) while the hand was accelerated in deviated postures, then Fr would increase even more,
resulting in even more stress on flexor tendon tissue. The large peak Fr in Figure 3.22 could possibly
cause the tendon and its sheath or the fibrous sheath moored to bone or ligament to hypertrophy or
inflame, which could result in tendinitis or tenosynovitis. The occurrence of either tendinitis or
tenosynovitis would most likely increase in Equation (3.5), thereby increasing Ft-max and Fr even more
(refer to Figure 3.21 and Equation (3.4)).
The large resultant reaction forces on the tendons from wrist deviation and accelerations could
possibly explain the findings of Armstrong et al. (1984), who investigated the histological changes in the
flexor tendons as they pass through the carpal tunnel. These investigators found hypertrophy and increased
density in the synovial tissue in the carpal tunnel area. These authors suggested that biomechanical
factors, such as repeated exertions with a flexed or extended wrist posture, could have partially caused
degenerative changes in tendon tissue. In addition to reaction forces from supporting structures, the
hypertrophy of the tendon tissue could have been caused by differences in strain within a tendon. In an
investigation of the viscoelastic properties of tendons and their sheaths, Goldstein et al. (1987) found

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FIGURE 3.21 Relationship between the maximum (Ft-max) and minimum (Ft-min) forces of a tendon and the resultant
reaction force (Fr). Ft-max is the force emanating from the forearm flexor muscles, and Ft-min is the force transmitted to
the hand. The flexor tendon is wrapped around the wrists carpal bones. Ft-max and Ft-min are the maximum and
minimum tendon forces in Schoenmarklins and Marrass (1990) dynamic model of a flexor tendon passing through
the wrist joint. The equation for Ft-max and Ft-min is from Leveau (1977). (From Schoenmarklin, R.W. and Marras,
W.S. 1990. In Proceedings of the 34th Meeting of the Human Factors Society, p. 807. With permission.)

that flexion/extension wrist angle increased the shear traction forces between tendons, their sheaths,
and bones and ligaments that form the anatomical pulley. As depicted in Figure 3.23, when the wrist is
extended approximately 10, the strain in the flexor digitorum profundus (FDP) tendons, which pass
through the carpal tunnel and move the fingers, is approximately 10% to 15% lower on the side distal
(hand side) to the flexor retinaculum than the proximal side (forearm side). This difference in strain
within a tendon creates shear traction forces, which are magnified when the wrist angle is deviated to
65 flexion or extension.

3.5 Work-Related CTDs Involving the Muscle-Tendon Unit

The pathogenesis of the most frequently studied CTDs involving the muscle-tendon unit will be discussed
below.

Tendinitis
Although tendinitis is defined as inflammation of the tendon, Moore (1992) contends there is scant
scientific evidence that the collagenous fibers that comprise the tendon actually inflame. According to
Moore (1992), tendinitis is often used as a term that implies soreness localized to a muscle-tendon unit
that increases with tensile load from either muscle contraction or passive stretch. Moore (1992) further
states that these clinical findings of soreness may represent no more than a normal pattern to varying
degrees of use, rather than inflammation. Because clinicians do not have sensitive diagnostic tools to
differentiate between tendinitis and tenosynovitis (inflammation of the tendons sheath), soreness in
joints where the tendons do not have sheaths, such as in the elbow and shoulder, is usually diagnosed as
tendinitis, whereas soreness in joints with sheathed tendons is commonly diagnosed as tenosynovitis.
One theory of the pathogenesis of tendinitis is the physical disruption of a small number of collagen
fibers within a tendon and the ensuing repair process. According to Moore (1992), the body responds to
this disruption in a manner similar to that of a partial tendon laceration, which is the partial cutting or
severing of a tendon. The healing process of the tendon occurs in three stages: inflammatory stage,

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FIGURE 3.22 The resultant reaction force (Fr) exerted by the carpal bones or flexor retinaculum against a flexor
tendon and its sheath as a function of wrist angle and acceleration. (From Schoenmarklin, R.W. and Marras, W.S.
1990. In Proceedings of the 34th Meeting of the Human Factors Society, p. 809. With permission.)

reparative or collagen-production stage, and a remodeling stage (Gelberman et al., 1988). As the body
rebuilds its tendon tissue, the collagen content increases and the tendon could hypertrophy, or increase
in size. In addition, the body may not repair all of the disrupted fibers, resulting in permanent fraying of
the tendon. Due to hypertrophy and fraying, the tendon may be biomechanically different, possibly
deficient, after the bodys attempt to completely restore the disrupted tissues.
Moore (1992) relates the effects of partial tendon laceration to CTDs in that when a joint is deviated
from a neutral position, the tendons could react to resulting reaction forces from the joint structures (Fr
in Equation (3.4) and Figures 3.21 and 3.22) in a manner similar to a partial tendon laceration. As
shown by Armstrong and Chaffins (1979) static model, as the wrist deviates, the resulting reaction
forces from the flexor retinaculum or carpal bones could cause physical disruption to the tendons, much
like the effects of partial tendon laceration. Theoretically, physical disruption of the tendon tissue would
be exacerbated by even greater reaction forces if the wrist were accelerated or decelerated, particularly at
extreme wrist deviation angles (Schoenmarklin and Marras, 1990). If the wrist and fingers were deviated
excessively in repetitive motions, hypertrophy of the tendons from the healing process or permanent
fraying of the tendons could cause soreness at the wrist. Depending on the specific tendon, this soreness
may be diagnosed as tendinitis or tenosynovitis. Soreness in the wrist flexor muscles tendons (flexor
carpi radialis and ulnaris) would probably be diagnosed as tendinitis because these tendons do not have
sheaths, whereas soreness in tendons passing through the carpal tunnel (flexor digitorum superficialis
and profundus) would commonly be diagnosed as tenosynovitis because these tendons are sheathed.

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FIGURE 3.23 The difference in strain within the flexor digitorum profundus tendon between measurements taken
proximal and distal to the flexor retinaculum. Even at an extended wrist angle of 10, there is a 10% to 15%
difference in strain between the FDP tendon proximal and distal to the flexor retinaculum. The difference in strain
is magnified as wrist deviation angle increases. (From Goldstein, S.A., Armstrong, T.J., Chaffin, D.B., and Matthews,
L.S. 1987. Analysis of cumulative strain in tendons and tendon sheaths. J. Biomed, 20, p. 4. With permission.)

Lateral Epicondylitis (Tennis Elbow)

Lateral epicondylitis, which is also called tennis elbow in lay parlance, is tendinitis of the forearm
extensor and supinator muscles at the lateral epicondyle of the elbow. The lateral epicondyle is the small
bony attachment point on the outside of the elbow where the group of forearm extensor and supinator
muscles originate. The extrinsic extensor and supinator muscles fuse into an aponeurosis, or a broad,
flat tendon, which is attached to the lateral epicondyle in the elbow. Soreness and pain occur at the point
where the aponeurosis of the extensor and supinator muscles pull on the lateral epicondyle. The small
size of the lateral epicondyle and the relatively large mass of extensor and supinator muscles create high
stresses on the lateral epicondyle and its attached aponeurosis. Patients who have lateral epicondylitis
report their pain is particularly acute when they extend their wrist or supinate the forearm against
resistance, which occurs when one is hitting a tennis ball with a backhand stroke.
Lateral epicondylitis is a CTD in that it is directly related to the motions that tense the wrists extensor
and supinator muscles (Nirschl, 1983). In a study of 113 patients, Goldie (1964) found that repeated
wrist extensions or alternating pronating and supinating movements of the forearm were causal factors
in 83 of the cases.
Review of the medical literature reveals several hypotheses regarding the pathogenesis of lateral
epicondylitis, although all of them do agree that the basic mechanism is deterioration of the aponeurotic
tendinous tissue at the lateral epicondyle. Cyriax (1936), who treated 20 patients with lateral epicondylitis,
concluded it is caused by a tear between the tendinous origin of the extensor muscles and the periosteum
of the lateral epicondyle. Goldie (1964) suggested that lateral epicondylitis is due to a buildup of lesions
in a space under the tendon and distal to the epicondyle. Microscopically, Nirschl (1985) found that the
affected tendon in lateral epicondylitis had a characteristic appearance of hypertrophy that was grayish,
edematous, and friable. Nirschl (1985) interpreted this medical description as a thick unhappy gray
tendon, weeping with edema. A normal tendon has collagen fibers that run parallel, but the tendons
afflicted with lateral epicondylitis look coarse and granular.
Often, a patient with lateral epicondylitis will wear a brace around the forearm near the elbow
(Froimson, 1971; Moore, 1992), as is often seen on tennis players. Although it has not been validated
experimentally, one of the theories of why the forearm brace is beneficial is based on biomechanics.
Figure 3.24 shows a free body diagram of the elbow as viewed from the head position. The tendons of

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the forearm extensor and supinator muscles are modeled as a single vector. When tightened, the brace
may keep the aponeurosis from vibrating against underlying bony tissue during repeated extending or
supinating exertions. In addition, when the forearm brace is tightened it compresses the aponeurosis
against the underlying structures, thereby creating a frictional force that resists, albeit partially, the pull
of the forearm extensor and supinator muscles. Theoretically, this frictional force would relieve the
lateral epicondyle of carrying the full tensile load of the aponeurosis. However, because the coefficient of
friction among the musculoskeletal tissues underlying the brace is probably very low, the reduction in
tensile load on the lateral epicondyle may be small and negligible or it may be large enough to retard
lateral epicondylitis. Experimental research is needed to determine whether this biomechanical theory
can explain the efficacy of forearm braces.

Supraspinatus Tendinitis (Rotator Cuff Syndrome)

Supraspinatus tendinitis, which is often called rotator cuff syndrome, is tendinitis of the muscle that
elevates the shoulder. Elevation of the shoulder in the frontal plane is called shoulder abduction. Pain is
felt on the acromion process, or bony top of the shoulder, when one abducts the shoulder, particularly
when the arm is holding a load or exerting a pushing force.
The pathogenesis of supraspinatus tendinitis is impingement of the bursa and supraspinatus tendon
as the shoulder is abducted. The superficial and deep muscles of the shoulder are shown in Figure 3.25.
The deltoid muscle, which covers the outside of the shoulder, and the supraspinatus muscle, which is a
smaller muscle under the deltoid and trapezius muscles and acromion, are the major abductors of the
shoulder. As shown in Figures 3.26a and 3.26b, abduction of the shoulder compresses the acromion
downward, thereby pinching the underlying bursa and supraspinatus tendon (Chaffin and Andersson,
1991). As illustrated in Figure 3.12, the bursa is a tubular synovial sheath whose purpose is to lubricate
the contact between the deltoid muscle and acromion and the supraspinatus tendon. However, if the
shoulder is abducted repeatedly, and particularly under heavy loads, the resulting impingement could
damage the bursa and supraspinatus tendon fibrils and produce fraying of the tendon. The relative
avascular nature of the supraspinatus tendon diminishes its capability to repair itself, thereby leading to
degeneration, as shown in Figure 3.26c (Moore, 1992). In addition, intramuscular pressure from muscle
fibers attached to the tendon can also diminish the reparative process of the tendon.

Tenosynovitis
Although tenosynovitis is defined as inflammation of the tendon sheath (Stedman, 1982), any tendon sheath
disorder is called tenosynovitis, regardless of the presence or absence of inflammation (Moore, 1992). As
shown in Figures 3.9 and 3.10, the tendon sheath is a tubular structure that wraps around a tendon and
contains synovial fluid to provide lubrication, protection, and repair assistance for the surrounded tendon
(Moore, 1992). Tenosynovitis is diagnosed only where tendons are sheathed, whereas tendinitis could occur
in a tendon regardless of whether it is sheathed. Usually, soreness in a sheathed tendon area is diagnosed as
tenosynovitis, whereas soreness in a tendon without sheathing is diagnosed as tendinitis.

DeQuervains Tenosynovitis
DeQuervains disease is the stenosing tenosynovitis of the tendons that abduct and extend the thumb
(abductor pollicis longus [APL] and extensor pollicis brevis [EPB]) (Williams and Ward, 1983). This
disease was named after a Swiss surgeon who observed the condition in 1895. The practical importance
of the muscles that flex, extend, and abduct the thumb cannot be overestimated. According to Bunnel
(1956), a hand without a thumb is no more than a hook. The APL and EPB are two of the thumbs
muscles that are necessary for dexterity and fine manipulations.
As shown in Figure 3.27, the tendons of the APL and EPB pass underneath the extensor retinaculum
of the wrist, and then they share the same synovial sheath on their way to the dorsal and lateral side of

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FIGURE 3.24 Free body diagram (FBD) analysis of the forearm extensor and supinator muscles and their tendinous
attachment (aponeurosis) to the lateral epicondyle. The view of the elbow is from the head looking down, with the
forearm in midposition (neither supinated or pronated). a) FBD of the elbow without a forearm brace. The force the
aponeurosis has to exert, Ft1, is equal to the tensile pull of the extensor and supinator muscles, Fm. b) The tightening
of the forearm brace around the forearm creates a frictional force, Ff, that opposes Fm, thereby lessening the force on
the aponeurosis, Ft2. (From Marklin, R.W. original artwork. With permission.)

the thumb (Lamphier, 1965). The APLs and EPBs common sheath, which is about 5 cm long, passes
over a bony depression called the radial styloid.
The APL and EPB tendons and their common sheath are subject to cumulative trauma because of their
position in the bony groove in the radial styloid. DeQuervains disease is caused by the friction of the two
tendons rubbing against each and against the long bony groove (Lamphier et al., 1965). DeQuer-vains
disease is a stenosing tenosynovitis in that the common synovial sheath thickens (refer to Figure 3.27),

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Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 3.25 a) Superficial muscles of the shoulder complex. The deltoid muscle is a major shoulder abductor. b)
Deep muscles of the shoulder complex. The supraspinatus muscle is responsible for initiating abduction of the
shoulder, after which the deltoid provides most of the abduction force. (From Basmajian, J.V. 1982. Primary Anatomy,
8th edition, p. 141, Williams and Wilkins, Inc. With permission.)

FIGURE 3.26 a) Normal shoulder structure with the arm hanging at the side. Bursa separates the deltoid muscle and
acromion from the supraspinatus tendon (rotator cuff tendon). b) When the shoulder is abducted, bursa and
supraspinatus tendon are pinched between the acromion and humerus bone (arm bone). c) With repeated abductions,
both the bursa and tendon could swell and degenerate and the tendon could fray. (From Chaffin, D.B. and Andersson,
G.B.J. 1991. Occupational Biomechanics, 2nd edition, p. 381, John Wiley & Sons Publishers. With permission.)

thereby increasing the friction between the APL and EPB tendons within their common sheath. In his
review of the medical literature, Moore (1992) described the pathogenesis of DeQuervains disease. In
mild cases, the synovial layer within the synovial sheath thickens up to twice the normal thickness. However,

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FIGURE 3.27 Abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons as they proceed under the
extensor retinaculum and through their common synovial sheath. DeQuervains disease is stenosing tenosynovitis of
the APL and EPB in their common sheath. (From Lamphier, T.A., Crooker, C., and Crooker, J.L. 1965. DeQuervains
disease. Industrial Medicine and Surgery, p. 848. With permission.)

FIGURE 3.28 A) Cross-section of a normal fibroosseus canal as it passes over the radial styloid. The tendon (a) and
its synovial sheaths (b) are moored to the radius bone (d) with a fibrous ligamentous sheath (c). B) Cross-section of
a fibroosseus canal with stenosing tenosynovitis. The tendons (a) are flattened, the synovial sheath (b) is thinned,
and the fibrous ligamentous sheath (c) is thickened. (From Finkelstein, H. 1930. Stenosing tendovaginitis at the
radial styloid process. J. Bone Jt Surg, Vol. 12, p. 515. With permission.)

at the point of constriction where the tendons rub against the radial styloid, the synovial sheath of the APL
and EPB tendons thin and the tendons flatten (Finkelstein, 1930), as illustrated in Figure 3.28. The thinning
of the tendon sheath and flattening of the tendons is caused by hypertrophy of the fibrous ligamentous
sheath, namely the extensor retinaculum, that holds the APB and EPB tendons and their common sheath
to the radial styloid bone. In severe cases, the fibrous ligamentous sheath thickens three to four times
(Lamphier et al., 1965), and the tendon could swell, forming a bulbous shape adjacent to the site of
constriction, as illustrated in Figure 3.29. This bulbous swelling could cause popping of the APL and EPB
tendons as the wrist is ulnarly deviated with the thumb flexed inside the palm.

Trigger Finger
Trigger finger is stenosing tenosynovitis of the tendons that flex the fingers and is manifested by painful
locking of the finger during finger flexion. As illustrated in Figure 3.30, the finger flexor tendons and

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Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 3.29 A) Longitudinal section of a normal fibroosseus canal. The tendon (a) is covered by it sheath (b). The
fibrous ligamentous sheath (c) forms a canal through which the tendon can travel unimpeded. B) Longitudinal
section of a fibroosseus canal with stenosing tenosynovitis. The tendon (a) and its synovial sheath (b) are thinned by
a thickened fibrous ligamentous sheath (c), forming a nodule in the tendon (d). (From Finkelstein, H. 1930. Stenosing
tendovaginitis at the radial styloid process. J Bone Jt Surg, Vol. 12, pp. 514 and 515. With permission.)

FIGURE 3.30 A finger flexor tendon as it traverses from the knuckle (left) to the tip (right). Fibrous ligamentous
sheaths comprise the five annular pulleys (A1-A5) and three cruciate pulleys (C1-C3). These pulleys hold the tendons
close to the finger joints to avoid bowstringing during finger flexion. (From Doyle, J.R. 1989. Anatomy of the finger
flexor tendon sheath and pulley system: A current review. J Hand Surg, 14A, p. 350. With permission.)

their synovial sheaths are moored to the bones of the finger with fibrous ligamentous sheaths to avoid
bowstringing during finger flexion. These fibrous ligamentous sheaths are called pulleys, of which there
are two types: annular (A1-A5) and cruciate (C1-C3). Repetitive and forceful flexing of the fingers
could cause trigger finger, whose pathogenesis is related to that of DeQuervains disease. As depicted in
Figure 3.29A, a normal fibroosseus canal allows the tendon to glide with no obstruction. However, in
the case of trigger finger, bulbous swellings, such as those shown in Figure 3.29B, will restrict the finger
flexor tendons from traversing through their fibrous ligamentous sheaths. If large enough, the bulbous
swellings could immobilize the tendon, thereby locking the finger in a fixed flexed position. In order to
unlock the finger, the bulbous swelling has to snap to move beyond the constriction in the fibroosseus
canal. External aid from the other hand may be required to extend the finger back to a straight, neutral
position (Rowe, 1985).
Although trigger finger tends to occur at the creases of the finger (Caillet, 1984), it occurs most
frequently near the knuckle (metacarpophalangeal joint) (Quinnel, 1980). The middle and ring fingers
are the predominant sites of trigger finger in the dominant hand, accounting for over 40% of the cases
in Quinnels (1980) study.

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3.6 Biomechanical Aspects of Nerve Compression Disorders

Nerve compression disorders are a group of disorders in which a peripheral nerve is compressed or
pinched, causing trauma to the immediate area served by the nerve and sometimes distal to the site of
impingement. The effects from the trauma could be temporary or long term. An example of a widely
known nerve disorder is sciatica, which is compression of the sciatic nerve in the lower back but whose
pain is felt throughout the areas of the lower leg served by the sciatic nerve.
Nerve compression disorders of the upper extremity can affect all three major nerves of the upper
extremity, namely the radial, ulnar, and median nerves (refer to Figure 3.13a). The most widely publicized
nerve compression disorder of the upper extremity is carpal tunnel syndrome, which is compression of
the median nerve at the site where it passes through the carpal tunnel in the wrist. Examples of lesser
known nerve compression disorders of the upper extremity are cubital tunnel syndrome and posterior
interosseous nerve syndrome, which are caused by compression of the ulnar and radial nerves, respectively.
The anatomy of a neuron is illustrated in Figure 3.31. Although neurons vary in size and shape, they
generally consist of a cell body (soma), dendrites, and an axon. The axon is the shaft of the nerve
through which electrical impulses travel. When the impulse reaches the axon terminal, it then crosses
over to the dendrites of an adjacent neuron. As shown in Figure 3.31, there are small gaps, called the
nodes of Ranvier, between segments of the axon. These segments are covered with a myelin sheath and
neurilemma (or Schwann cells), which insulate the nerve fibers from adjacent cellular compartments and
allow the electrical impulse to travel from node to node (Van de Graaf and Rhees, 1987). The speed of
an impulse traveling through a neuron is called conduction velocity. A cross-sectional view of the axon
of a neuron reveals three layers of connective tissue that hold the nerve fibers together and protect them.
As illustrated in Figure 3.32, the epineurium is the most external layer, holding together several fasciculi.
Several fasciculi surrounded by epineurium is called a single nerve (Spence, 1986). The perineurium,
which consists of fibrous collagen, surrounds each fasciculus or bundle of nerve fibers. The endoneurium
is the connective tissue within each fasciculus and forms a tube-like membrane around each nerve fiber
(Szabo and Gelberman, 1987).
Although the pathogenesis of nerve entrapment syndromes is controversial, two prominent theories
have been hypothesized (Moore, 1992). These two theories are first, mechanical compression of the
nerve, and second, inadequate blood supply serving the nerve. The first theory, mechanical compression,
is described in detail in Feldman et al. (1983) and Szabo and Gelberman (1987) and is summarized
below. Any physical disturbance to the nerve can cause motor or sensory dysfunction. An impingement
upon the efferent portion of the nervecarrying impulses to the peripheral nervous system from the
brain and spinal cordcan result in loss of muscular strength. Likewise a disturbance to the afferent
portioncarrying impulses to the central nervous system from receptors located throughout the body
can decrease sensory feedback. Myelinated nerves are more susceptible to the effects of pressure than
unmyelinated nerves. Since motor nerves consist predominantly of thick myelinated fibers, the motor
nerves are theoretically more susceptible to the effects of compression than sensory cutaneous nerves
(Feldman et al., 1983). However, based on clinical observations of nerve entrapment syndromes, the
sensory function appears to show decrements before motor function (Szabo and Gelberman, 1987). The
pathogenesis of why sensory decrements are manifested before motor decrements is still unclear.
Compression can cause neural dysfunction in the following manner. First, compression causes bulbous
swellings on the fibers (Aguayo, 1975), which can block conduction of electrical impulses. If compression
continues, the myelin between nodes on the nerve becomes thinner, and the fibers start to segmentally
demyelinate, which can further decrease the conduction velocity of nerve impulses (Feldman et al., 1983).
The second prominent theory posed to explain the pathogenesis of nerve entrapment syndromes is
insufficient blood supply to the nerves (Moore, 1992). Ischemia, or inadequate circulation due to mechanical
obstruction in the nerves path, can cause symptoms typical of nerve entrapment syndromes, such as
paresthesia or acute pain and possibly a reduction in conduction velocity. The mechanical obstruction
could take the form of pinching or entrapment of the nerve as the nerve travels around tendons, ligaments,

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FIGURE 3.31 Structure of a typical motor neuron. (From Spence, A.P. 1986. Basic Human Anatomy, The Benjamin
Cummings Publishing, Inc., p. 348. With permission.)

or bones in a joint. Vascular deficiencies and changes in blood pressure could account for the variation
in symptoms noted in patients with approximately equal levels of nerve conduction delay (Shivde et al.,
1981; Moore, 1992). In one study, vascular sclerosis was observed in 98% of the carpal tunnel cases
(Fuchs et al., 1991).
The nerve fiber distal to the site of compression or physical trauma, whether by compression or
inadequate blood supply, can also be detrimentally affected. Wallerian degeneration is the deterioration
of the myelin sheath distal to the site of trauma and can lead to atrophy and destruction of a neuron.
Wallerian degeneration is caused by impaired flow of electrical impulses down the nerves axon and
ischemia (Feldman et al., 1983). Ogata and Naito (1986) investigated the effects of compression and

Biomechanical Aspects of CTDs

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FIGURE 3.32 Cross section of a single peripheral nerve, which is composed of several fasciculi wrapped in epineurium
connective tissue. The perineurium wraps each fasciculus, and the endoneurium encases each single nerve fiber.
(From Spence, A.P. 1986. Basic Human Anatomy, The Benjamin Cummings Publishing, Inc., p. 353. With permission.)

stretching of nerves, and they found that compression and stretching do restrict blood flow to the
nerves, even to the point of arresting blood flow. In addition to Wallerian degeneration, compression of
a nerve can impede nerve conduction and lower conduction velocity distal to the site of trauma, resulting
in decreased motor and sensory function such as muscle atrophy and paresthesia, respectively (Feldman
et al., 1983).
In the upper extremity, peripheral nerves can be compressed at any point along its path, ranging from
the wrist (carpal tunnel syndrome) to the shoulder (thoracic outlet syndrome). These two syndromes are
described and discussed below.

3.7 Work-Related CTDs Involving the Nerve

Carpal Tunnel Syndrome
Carpal tunnel syndrome (CTS) is a nerve entrapment disorder arising from compression of the median
nerve at the site where it travels through the carpal tunnel in the wrist. Although CTS was first recognized
by Sir James Paget more than a century ago (1860), the name CTS was not uniformly applied to
compression of the median nerve until the late 1950s (Phalen, 1981). Prior to and through the early
1950s, CTS was referred to with long, clumsy names, such as spontaneous compression of the median
nerve in the carpal tunnel and compression secondary to trauma, tumor, or systemic disease. The
much shorter, more facile name, carpal tunnel syndrome, started to gain acceptance in the late 1950s
to include all conditions that might cause compression of the median nerve, regardless of the source of
compression. In 1957, Phalen and Kendrick stated, The term carpal tunnel syndrome is now used to
describe all cases of compression neuropathy of the median nerve at the wrist (Moore, 1992).
The symptoms of CTS involve the motor, sensory, and autonomic functions of the median nerve
(Armstrong, 1983):

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1. Motor nerve impairment: reduced motor control and atrophy of the abductor pollicis brevis, a
major thumb abductor located at the base of the thumb, and weakness in precision grip (Feldman
et al., 1983). A patient with severe and long-standing CTS may show a severely diminished
musculature at the thenar eminence, which is the protruding area at the base of the thumb.
2. Sensory nerve impairment: paresthesia (burning, prickling, and tingling) and hypesthesia
(diminished sensitivity to stimulation) in the thumb and fore, middle, and one half of the ring
fingers and in the thenar eminence on the palmar side; paresthesia and hypesthesia on the distal
phalanges of the thumb and same fingers on the dorsal side of the hand (refer to Figure 3.14).
3. Autonomic nerve impairment: diminished sweat function, resulting in dry and shiny skin in areas
noted in sensory nerve impairment.
Of all the tissues that pass through the carpal tunnel at the wrist, the median nerve is the softest and
most vulnerable to pressure. As illustrated in Figure 3.8, the median nerve along with nine forearm
flexor tendons pass through the carpal tunnel, which is formed by the carpal bones on the dorsal side of
the hand and the flexor retinaculum on the palmar side. In 1963, Robbins conducted a systematic study,
considered by some to be the most thorough, of the anatomy of the carpal tunnel (Moore, 1992). He
analyzed cross sections of cadaveric wrists dissected at distances 2 to 4 cm proximal and distal to the
wrist crease. Among Robbinss (1963) major findings were:
1. The cross-sectional area of the carpal tunnel decreases from its proximal entrance to a point 2 cm
distal from its origin. He said the effect is to have a canal with a slightly narrowed waist.
2. All the structures are crowded in the canal, and in 6 of the 7 specimens, the median nerve was
flattened and directly beneath the flexor retinaculum.
3. When the wrist was in a neutral position in the cadaveric specimens, Robbins (1963) inserted
and withdrew a piece of rubber easily underneath the flexor retinaculum. However, when the
wrist was flexed or extended, the resistance increased concomitantly with the angle of deviation.
Considerable force was required to withdraw the rubber proximally in either of the extreme
flexed or extended positions. Robbins (1963) concluded the volume of the carpal tunnel decreases
as the wrist is deviated in either flexion or extension.
Patients with CTS show a significant elevation of pressure in the carpal tunnel. At a neutral posture,
Gelberman et al. (1981) found that the mean pressure in the carpal tunnel of patients with CTS was 32
mmHg, compared to 2.5 mmHg for control subjects. These researchers also showed that 90 of wrist
flexion and extension increased the pressure precipitously to approximately 100 mmHg and 32 mmHg
for the CTS patients and healthy subjects, respectively.
Although the pathophysiology of CTS is unknown, researchers have postulated thickening of the
flexor tendon sheaths in CTS patients as contributing to the increase in pressure in the carpal tunnel. In
a study of 212 wrists surgically treated for CTS, Phalen (1966) observed thickening or fibrosis of the
flexor synovium in 203 of the cases. Biopsy specimens of the flexor synovium from 181 of the 212
wrists revealed chronic fibrosis or thickening in 91 specimens, chronic inflammation compatible with
symptoms of rheumatoid arthritis in 64, and no pathologic change in 26. Yamaguchi et al. (1965)
observed microscopically an aging effect on the flexor tendon sheaths, manifested by fibrous thickening
of the sheaths. They compared the sheath anatomy of CTS patients vs. healthy controls, and they found
that almost 90% of the patients exhibited a greater increase in thickening and fibrosis of the sheaths
than the healthy control subjects. Kerr et al. (1992) observed hypertrophy of the synovium of the flexor
tendons, with little or no evidence of inflammation, in patients with CTS. Schuind et al. (1990) observed
fibrous hypertrophy and necrotic lesions in flexor synovium typical of a connective tissue undergoing
degeneration under repeated mechanical stresses. The experimental findings of Armstrong et al. (1984)
support Schuinds (1990) association between degeneration of tendon tissue and mechanical stress.
Synovial hypertrophy and the mean densities of subsynovium and adjacent connective tissue were

Biomechanical Aspects of CTDs

3-29

significantly greater at the wrist crease as compared to locations proximal and distal to the crease.
Armstrong et al. (1984) concluded that repeated exertions with a flexed or extended wrist are an important
factor in the etiology of the degeneration and hypertrophy of tissue surrounding the tendon.

Occupational Sources of Median Nerve Compression in CTS

The three main occupational risk factors of CTS (wrist repetition, deviated wrist angle, and tendon
force), along with the basic anatomical structure of the wrist, can increase the pressure in the carpal
tunnel, compress the median nerve, and result in the following:
1. Increase in carpal tunnel pressure at deviated wrist angles due to reduction in tunnel volume.
According to Robbins (1963), extreme flexion and extension of the wrist reduced the volume of
the carpal tunnel, thereby augmenting the pressure on the median nerve. This increase in tunnel
pressure would, theoretically, affect the median nerve first because it is the softest and most
vulnerable tissue in the carpal tunnel.
2. General increase in tunnel pressure from wrist deviation. Deviation of the wrist in the flexion/
extension plane has been shown repeatedly in the anatomical and physiological literature to
increase the pressure in the carpal canal (Phalen, 1966; Smith et al., 1977). In a flexed or extended
wrist posture, the median nerve is squeezed between the flexor retinaculum and the overlying
flexor tendons, thereby exposing a worker to CTS. Recently, Rempel et al. (1994) measured the
carpal tunnel pressure of subjects typing on a computer keyboard elevated at various slopes to
extend the wrist at five different angles. As shown in Figure 3.33, these researchers found that the
pressure in the carpal tunnel was lowest at a neutral position compared to postures up to 50
extension and 20 flexion. The approximately 100 mmHg maximum pressures Rempel et al.
(1994) measured were in the same range as in Gelbermans et al. (1981) study. In addition to the
flexion/extension plane, carpal tunnel pressure has been shown to increase as the wrist radially
and ulnarly deviates from a neutral posture. Sommerich (1994) measured the carpal tunnel
pressures of four subjects typing on a standard QWERTY computer keyboard and an alternative
keyboard split and angled to reduce ulnar deviation. She found that all subjects showed a decrease
in carpal tunnel pressure with a concomitant decrease in ulnar deviation. The maximum carpal
tunnel pressures of 80 mmHg measured in Sommerichs (1994) study were similar to those
measured in the studies of Gelberman et al. (1981) and Rempel et al. (1994).
3. Thickening and fibrosis of synovium and hypertrophy of synovial sheaths. The well-documented
reporting of thickening of the flexor sheaths and synovium in the carpal tunnel (Phalen, 1966;
Yamaguchi et al., 1965; Armstrong et al., 1984; Schuind et al., 1990; and Kerr et al., 1992) could
possibly be explained by the biomechanical models of Armstrong and Chaffin (1979) and
Schoenmarklin and Marras (1990). The resultant reaction force on the flexor tendons and the
median nerve passing through the carpal tunnel increases concomitantly, not only with deviation
angle (Fr in Figures 3.18 and 3.19 from Armstrong and Chaffin [1979]), but also with acceleration
of the wrist (Fr in Figures 3.21 and 3.22 from Schoenmarklin and Marras [1990]). Wrist deviation
and acceleration are the static and dynamic components of repetitive movements of the wrist,
which have been associated with CTS.
In order to accelerate the wrist, the extrinsic muscles in the forearm have to exert force which is transmitted
to the tendons. As modeled by Schoenmarklin and Marras (1990), some of the force transmitted through
the tendon is lost to friction against the ligaments and bones that form the carpal tunnel (refer to Figure
3.21). This frictional force could irritate the tendons and their sheaths and possibly cause the synovitis
and hypertrophy found experimentally in the carpal tunnel. Armstrong et al. (1984) found sizeable
increases in synovium and synovial density in the carpal tunnel area, which they attributed to repeated
flexion/extension exertions. From a modeling point of view, Tanaka and McGlothlin (1989) hypothesized

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Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 3.33 Carpal tunnel pressure in one subjects wrist while typing on a computer keyboard set at different
wrist extension angles. (From Rempel, D. and Horie, S. 1994. Effect of wrist posture during typing on carpal tunnel
pressure. In Proceedings of Working With Display Units: Fourth International Scientific Conference, Milan, Italy, p.
C27. With permission.)

that the friction between tendons and adjacent structures is a major cause of CTDs and CTS, and Moore
and Wells (1989) and Moore et al. (1991) showed that the frictional work generated in the carpal tunnel
supported Silversteins et al. (1986, 1987) dose-response relationship between repetition and CTD risk.
In theory, the deleterious effects of frictional work generated between the tendons and their sheaths
or supporting structures is exacerbated by coactivation of the forearm extensor muscles during movements
of the wrist and hand. In order for the hand to maintain the same flexor torque or power/pinch force,
the flexor muscles have to exert more force to overcome the extensor force. Greater forces in the flexor
muscles will generate, in theory, increased frictional work between the flexor tendons and their adjacent
structures, thereby exposing workers to an increased risk of CTS.
Coactivation of antagonist muscles during static and dynamic contractions of the agonist muscles
have been found experimentally and modeled (Schoenmarklin and Marras, 1992; Marras and Sommerich,
1991a,b; Marras, 1992). With regard to hand grip exertions, Grant et al. (1992) measured the
electromyographic (EMG) signal of the forearm flexor and extensor musculature while subjects gripped
various diameters of handle, and these researchers found contractions of the extensor muscles (which
act as antagonists in this case) up to 30 % maximum valuntary contraction (MVC). Coactivation of the
extensors stabilizes the wrist during flexion movements (and vice versa, coactivation of the flexors
stabilizes the wrist during extension movements), and coactivation of the extensors also helps guide and
stabilize the hand while it exerts a power or pinch force.

Biomechanical Aspects of CTDs

3-31

FIGURE 3.34 Abduction of the shoulder causes the neurovascular bundle, containing the brachial plexus nerve and
subclavian artery, to be stretched under the pectoral muscles. Hypertrophy of the pectoral muscles would impinge
the neurovascular bundle, thereby causing deficiencies in the neural and circulatory systems of the upper extremity.
(From Putz-Anderson, V. 1988. Cumulative Trauma Disorders: A Manual for Musculoskeletal Diseases of the Upper
Limbs, p. 20, Taylor & Francis. With permission.)

Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a neurovascular disorder that affects the bundle carrying nerves,
arteries, and veins from the neck through the shoulder and into the arm, as illustrated in Figure 3.34.
This neurovascular bundle, which contains the brachial plexus nerve and the subclavian artery and vein,
could be compressed by adjacent muscles in the shoulder region, such as the scalene, subclavius, or
pectoralis minor, or the bones forming the thoracic outlet in the shoulder. The motions and tasks that
are associated with TOS are repetitive shoulder abduction and adduction, carrying heavy loads on the
shoulder, and working overhead (Feldman et al., 1983).
The pathogenesis of TOS is hypertrophy of the subclavius or pectoral muscles, which can pinch the
neurovascular bundle and produce symptoms in the neural and circulatory system throughout the arm.
Compression of the brachial plexus, which branches out into the median and ulnar nerves, can cause
numbness or paresthesia in the lower parts of arm and hand served by the median and ulnar nerves. An
impinged subclavian artery, which is the major artery supplying the upper extremity (refer to Figure
3.35), will result in ischemia, a reduction of blood flow to shoulder and arm (Basmajian, 1982). This
diminished blood flow will reduce the amount of oxygen and nutrients available for dynamic arm
movements and exacerbate the fatiguing effect from static (anaerobic) contractions by reducing the
amount of blood needed to carry away lactate and metabolites.

3.8 Summary
In this chapter, major CTDs that affect the soft tissues of the body and have been associated with workrelated activity are categorized into three groups: CTDs affecting muscle, the muscle-tendon unit, and
nerve. The anatomy of the upper extremitys musculoskeletal system was described, followed by a
discussion of biomechanical mechanism(s) that theoretically explain, in part, the epidemiological
associations between respective categories of CTD and work-related activity. In addition, each CTDs is
described in detail along with its pathogenesis.

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Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 3.35 The subclavian artery, which branches off into several arteries, is the major artery that serves the
upper extremity. Compression of the subclavian artery can cause ischemia and paresthesia in the arm and hand.
(From Basmajian, J.V. 1982. Primary Anatomy, 8th edition, p. 274, Williams and Wilkins, Inc. With permission.)

Defining Terms
Abduct (abduction): Literally means to to lead away from. In anatomical parlance, abduction is
moving a joint away from the center of the body. Shoulder abduction is elevating the arm in the
frontal plane.
Acromion process: The bony top of the shoulder. The acromion is actually the highest part of the
scapula bone, which spans the back of the shoulder.
Adduct (adduction): Literally means to lead towards. Adduction of a joint is moving the joint toward
the center of the body. Shoulder adduction is moving the shoulder towards the side of the torso.
Afferent nerves: Nerves that travel from the peripheral nervous system to the central nervous system,
namely the brain and spinal cord.
Agonist muscle: Muscle that initiates and carries out motion (Chaffin and Andersson, 1991).
Antagonist muscle: Muscle that opposes the action of the agonist muscle (Chaffin and Andersson,
1991).
Aponeurosis: A broad, flat tendon. An aponeurosis usually occurs at the point where the tendons from
several muscles fuse and connect to a bone.
Atrophy: A wasting of tissues or organs. A severe case of carpal tunnel syndrome will show atrophy of
the muscles in the thenar eminence.
Autonomic: Relating to the autonomic nervous system, which is part of the efferent division of the
peripheral nervous system. The autonomic nervous system is the involuntary system functioning
below the conscious level, that controls the heart, organs, and glands of the body (Spence, 1982).
Patients with carpal tunnel syndrome may display dry and shiny palms, resulting from insufficient
activity of the sweat glands in the hand, which are controlled by the autonomic nervous system.
Avascular: Nonvascular; without blood vessels (Stedman, 1982).
Axon: The shaft of a neuron that transmits electrical impulses (Spencer, 1986).

Biomechanical Aspects of CTDs

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Bursa: A structure resembling a collapsed bag with cellophane-thin walls whose inner surfaces are
extremely smooth, moist, and slippery. A bursa usually forms where a tendon rubs back and forth
on a hard structure. For example, rotator cuff syndrome is the deterioration of the bursa that lubricates
the shoulder bone from a tendon whose muscle raises the shoulder (Basmajian, 1982).
Carpal tunnel: The tunnel formed by eight small bones of the wrist and the transverse carpal ligament
(flexor retinaculum). The tendons that connect the forearm flexor muscles to the fingers pass through
the carpal tunnel.
Carpal tunnel syndrome: Compression of the median nerve as it passes through the carpal tunnel.
Central nervous system (CNS): The nervous system consisting of the brain and spinal cord. The CNS is
the integrative and control center of the body. The CNS receives sensory input from the peripheral
nervous system (PNS) and develops response strategies to the input (Spence, 1986).
Conduction velocity: The velocity at which an electrical impulse travels through a nerve. Conduction
velocity, which for a motor nerve is normally 50 to 60 m/s (Johnson, 1989). When the impulse
reaches muscle fiber, its conduction velocity slows down to about 3 to 6 m/s (Basmajian and DeLuca,
1985).
Cumulative trauma disorders (CTDs): Any of a class of pathologies affecting soft tissues (muscles,
tendons, and nerves) created from excessively frequent use of a particular joint or tissue, especially
in combination with awkward positioning, inadequate or no rest periods, or excessive loads. Also
called repetitive strain injury (RSI), repetitive stress injury, repetitive motion injury, and overuse
syndrome (Stramler, 1993).
Dendrites: Thin extensions emanating from the cell body of a neuron that receive electrical impulses
from adjoining neurons (Spence, 1986).
DeQuervains tenosynovitis: A narrowing of the passage (stenosing tenosynovitis) of the tendons and
their sheaths that extend the thumb in the palmar plane.
Disease: Illness, sickness, or cessation of bodily functions, systems, or organs. A disease is characterized
usually by at least two of the following criteria: a recognized causal agent(s), an identifiable group of
signs and symptoms, or consistent anatomical alterations (Stedman, 1982). Compare to Syndrome
and Disorder.
Distal: Located away from the center of the body or point of origin. For example, the wrist is distal to
the elbow, and the elbow is distal to the shoulder (Stedman, 1982).
Disorder: A disturbance of the functions, structure, or both resulting from a failure in development or
from external factors such as physical contact, injury, or disease (Stedman, 1982). Compare to
Disease and Syndrome.
Dorsal: Pertaining to the back of an anatomical structure, as in the dorsal (back) side of the hand.
Edema: An accumulation of an excessive amount of watery fluid in cells, tissues, or cavities (Stedman,
1982).
Efferent nerves: Nerves that travel from the brain and spinal cord in the central nervous system to the
outlying areas in the peripheral nervous system.
Endoneurium: Thin connective-tissue sheath that wraps each individual nerve fiber (Spence, 1986).
Epicondyle: A projection from a long bone above an articulating joint.
Epineurium: Connective-tissue sheath that surrounds several fasciculi in a nerve. Several fasciculi
surrounded by epineurium constitute a single nerve (Spence, 1986).
Etiology: The science and study of the causes of disease and their mode of operation (Stedman, 1982).
Compare to Pathogenesis.
Extend (extension): Movement of a body part that increases the angle of its adjacent joint. For example,
moving your hand away from your shoulder requires elbow extension.
Extensor retinaculum: A strong fibrous ligament that stretches across the back of the hand at the wrist.
The extensor retinaculum holds the forearm extensor tendons close to the carpal bones of the wrist.
Extrinsic muscles: Flexor and extensor muscles in the forearm that generate much of the movement and
force production of the hand and fingers. The extrinsic muscles can also be recruited for hand
movements and forces requiring fine motor control.

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Occupational Ergonomics: Engineering and Administrative Controls

Fasciculus (fasciculi): A bundle of nerve fibers surrounded by connective tissue (perineurium) (Spence,
1986).
Fibroosseus canal: A canal formed by a fibrous ligamentous sheath and an underlying bone. DeQuervains disease and trigger finger are thickening of the fibrous ligamentous sheath, resulting in a
thinning of the tendon and its synovial sheath that pass through the canal.
Flex (flexion): Movement of a body part that decreases the angle of its adjacent joint. For example,
moving your hand toward your shoulder requires elbow flexion.
Flexor retinaculum: The transverse carpal ligament that stretches across the palmar side of the wrist.
The flexor retinaculum, which forms the top of the carpal tunnel, holds the flexor tendons and their
sheaths inside the wrist.
Frictional force: A force that impedes impending motion.
Frontal plane: The plane of the body that travels through the chest and arms. The frontal plane shows
the front of the body. Also called coronal plane.
Humerus: The arm bone connecting the shoulder to the elbow.
Hypertrophy: General increase in the bulk of a part or organ that is not due to tumor formation (Stedman,
1982). Compare to Inflame.
Hypesthesia (hypoesthesia): An abnormal sensation characterized by diminished sensitivity to stimulation
(Stedman, 1982).
Hysteresis: The difference in the stress-strain response of a material to an increasing load or decreasing
load. With tendons, the stress required to maintain a certain amount of strain is less when the force
is decreasing than when increasing.
Innervate: To supply nerve function to a specific muscle group.
Insert (insertion): The distal attachment point of a muscle to bone, via a tendon.
Inflame: Pathologic process consisting of a histologic reaction to affected blood vessels and adjacent
tissues in response to an injury or abnormal stimulation caused by a physical, chemical, or biologic
agent (Stedman, 1982). Compare to Hypertrophy.
Intrinsic muscles: The small muscles located within the hand that move the thumb and fingers. The
intrinsic muscles, which are much smaller than the extrinsic muscles in the forearm, are used primarily
for motions and forces requiring dexterity and fine motor control.
Ischemia: Inadequate circulation of the blood due to mechanical obstruction, mainly arterial narrowing
(Stedman, 1982).
Lateral epicondyle: A bony protrusion located on the lateral side of the elbow. Viewed from the side, the
lateral epicondyle is located close to the pivot point of the elbow as it flexes and extends.
Lateral epicondylitis (tennis elbow): Tendinitis of the forearm extensor and supinator muscles at the
lateral epicondyle of the elbow. Lateral epicondylitis is colloquially dubbed tennis elbow because
patients with lateral epicondylitis report pain when the wrist is extended and supinateda movement
similar to that of a back stroke in tennis.
Ligament: Connective tissue resembling a tendon except a ligament attaches bone to bone (Basmajian,
1982).
Median nerve: The great flexor nerve of the upper extremity. It supplies motor function to the forearm
flexor muscles and the thumbs (thenar) muscles and sensory function to the palm and the digits
from the thumb to the center of the ring finger (Basmajian, 1982).
Morbidity: A diseased state (Stedman, 1982).
Muscle: A contractile organ of the body that moves various body parts and internal organs. A muscle
can only pull (tensile force) and not push (compression force). The origin of a muscle is the end that
is more fixed and the insertion of a muscle is the end that is more movable. For example, the flexor
muscles of the forearm originate at the elbow and insert at the wrist and fingers (Stedman, 1982).
Myalgia: Muscular pain.
Myelin sheath: A sheath that surrounds the axon of a neuron. The purpose of the myelin sheath is to
insulate the neuron from adjacent cellular fluids so an electrical impulse can travel down the axon
jumping from one node of Ranvier to the next.

Biomechanical Aspects of CTDs

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Myofascial syndrome: Term referring to regional muscle pain syndromes (Kuorinka and Forcier, 1995).
Myopathy: Term for measurable pathological changes in a muscle with or without symptoms (Kuorinka
and Forcier, 1995).
Nerve: A collection of nerve fibers in the peripheral nervous system (Spence, 1986).
Nerve fiber: Any long process of a neuron. The term usually refers to axons, but also includes the
peripheral processes of sensory neurons (Spence, 1986).
Neurilemma: The thin membrane between the myelin and connective tissue (endoneurium) in a neuron.
Neurilemma is also called the sheath of Schwann (Spence, 1986).
Neuron: A nerve cell (Spence, 1986).
Neurovascular: Pertaining to the nervous and circulatory systems of the body.
Nociceptor: A peripheral nerve organ or mechanism that senses pain or injurious stimuli and transmits
them (Stedman, 1982).
Nodes of Ranvier: Gaps in the myelin sheath and neurilemma of a neurons axon. Electrical impulses
known as potentials travel down the axon from one node to the next, which is called saltatory
conduction. (The etymology of saltatory is from the Latin word saltare, meaning to dance.)
Origin (originate): The proximal attachment point of a muscle to bone, via a tendon.
Paresthesia: An abnormal sensation, such as of burning, prickling, tickling, or tingling (Stedman, 1982).
Pathogenesis: The mode of origin or development of any disease or morbid process (Stedman, 1982).
Compare to Etiology.
Periosteum: Thick fibrous membrane covering the surface of a bone (Stedman, 1982).
Peripheral nervous system: All nervous structures located outside the central nervous system (CNS),
which consists of the brain and spinal cord. The PNS consists of nerves that connect the outlying
parts of the body and their receptors with the brain and spinal cord (Spence, 1986).
Phalanx (phalanges): One of the long bones of the fingers (Stedman, 1982). A finger has three phalanges:
distal (tip), middle, and proximal (connected to the knuckle).
Proximal: Located toward the center of the body or point of origin. For example, elbow is proximal to
the wrist, and the shoulder is proximal to the elbow (Stedman, 1982).
Radial deviation: Rotation of the wrist joint toward the radius bone or thumb side. Sometimes radial
deviation is referred to as abduction of the wrist joint.
Sclerosis: The process of becoming hard or firm. In the case of arteriosclerosis, the walls of the arteries
harden and become less elastic. The blood vessels are unable to expand and recoil in response to
pressure changes, thereby elevating ones maximum blood pressure (Spence, 1986).
Shoulder-neck myofascial syndrome: See Tension neck syndrome.
Stenosing tenosynovitis: A narrowing of the canal through which a tendon and its sheath pass.
Striated muscle: Muscle that appears striped with dark and light bands under a microscope. Also called
skeletal muscle, which are the muscles that move the limbs, head, neck, and torso.
Supraspinatus tendinitis (rotator cuff syndrome): Tendinitis of the supraspinatus muscle, which abducts
the shoulder from the side of the trunk. Supraspinatus tendinitis is often called rotator cuff
syndrome.
Syndrome: The collection of signs and symptoms associated with any disease process and constituting
the picture of the disease (Stedman, 1982). Compare to Disease and Disorder.
Synovial fluid: A clear fluid whose purpose is to lubricate a tendon within a sheath or a joint (Stedman,
1982).
Synovial sheath: An elongated and double-walled tubular structure (bursa) that surrounds a tendon and
allows the tendon to travel with little friction. Synovial sheaths are located where tendons move
around joints, such as in the wrist (Basmajian, 1982).
Tendon: Connective tissue resembling a tough cord or band and always part of a muscle, usually forming
an attachment of muscle to bone (Basmajian, 1982).
Tendinitis (also spelled tendonitis): Inflammation of a tendon (Stedman, 1982).
Tenosynovitis: Inflammation of a tendons sheath (Stedman, 1982). Clinically, any tendon sheath disorder
is called tenosynovitis, regardless of the presence or absence of inflammation (Moore, 1992).

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Occupational Ergonomics: Engineering and Administrative Controls

Tension neck syndrome (TNS): Myalgia in the shoulder-neck region of the body. TNS is synonymous
with shoulder-neck myofascial syndrome, and TNS is defined by symptoms of pain in the shoulderneck region with simultaneous findings of tenderness over the shoulder-neck muscles (Kuorinka and
Forcier, 1995).
Thenar eminence: The area at the base of the thumb that is raised above the general level of the palm.
The thenar eminence contains the intrinsic musculature that controls the thumb.
Thoracic outlet syndrome: A neurovascular disorder that affects the brachial plexus nerve and the
subclavian artery and vein as they traverse through the thoracic outlet in the shoulder. The early
symptoms of thoracic outlet syndrome are found in the areas in the forearm and hand served by the
median and ulnar nerves.
Trigger finger: Painful locking of a finger caused by narrowing of the canal through which a finger
flexor tendon and its sheath pass.
Ulnar deviation: Rotation of the wrist joint toward the ulna bone or little finger side. Sometimes ulnar
deviation is referred to as adduction of the wrist joint.
Wallerian degeneration: Degeneration of the myelin sheath of a neurons axon caused by compression of
the nerve and ischemia. Wallerian degeneration leads to the atrophy and destruction of the neuron
(Stedman, 1982).

References
Abrahams, M. Mechanical analysis of tendon in vitro: A preliminary report. Med Biol Eng, 5:433443, 1967.
Aguayo, A.J. Neuropathy due to compression and entrapment, in Peripheral Neuropathy, Dyck, P.J.
and Lambert, E.H., editors, 688713, [Link] Co., 1975.
Armstrong, T.J. An ergonomics guide to carpal tunnel syndrome. Ergonomics Guides, American Industrial
Hygiene Association, 1983.
Armstrong, T.J., Castelli, W.A., Evans, F.G., and Diaz-Perez, R.D. Some histological changes in carpal
tunnel contents and their biomechanical implications. Journal of Occupational Medicine, 26, No.
3, 197201, 1984.
Armstrong, T.J. and Chaffin, D.B. Some biomechanical aspects of the carpal tunnel. Journal of
Biomechanics, 12, 567570, 1979.
Basmajian, J.V. Primary Anatomy, Eighth edition. Williams and Wilkins, 1982.
Basmajian, J.V. and DeLuca, C.J. Muscles Alive: Their Functions Revealed by Electromyography, Fifth
edition. Williams and Wilkins, 1985.
Brand, P.W. Clinical Mechanics of the Hand. The [Link] Co., 1985.
Bunnel, S. Surgery of the Hand, [Link] Co., 1956.
Caillet, R. Hand Pain and Impairment. Philadelphia, [Link] Co., 1984.
Chaffin, D.B. and Andersson, G.B.J. Occupational Biomechanics, Second Edition. John Wiley & Sons, 1991.
Cyriax, J.H. The pathology and treatment of tennis elbow, Journal of Bone and Joint Surgery, 18, 921
940, 1936.
Elliot, D.H. Structure and function of mammalian tendon. Biol Rev, 40:392421, 1965.
Feldman, R.G., Goldman, R., and Keyserling, W.M. Peripheral nerve entrapment syndromes and
ergonomic factors. American Journal of Industrial Medicine, 4, 661681, 1983.
Finkelstein, H. Stenosing tendovaginitis at the radial styloid process. Journal of Bone and Joint Surgery,
12, 509540, 1930.
Froimson, A.I. Treatment of tennis elbow with forearm support band. Journal of Bone and Joint Surgery,
53A:183184, 1971.
Fuchs, P.C., Nathan, P.A., and Myers, L.D. Synovial histology in carpal tunnel syndrome. Journal of
Hand Surgery, 16A, 753758, 1991.
Fung, Y.C. Biomechanics: Mechanical Properties of Living Tissues. Springer-Verlag, 1981.
Gelberman, R.H., Hergenroeder, P.T., Hargens, A.R., Lundbor, G.N., and Akeson, W.H. The carpal tunnel
syndrome: A study of carpal canal pressures. Journal of Bone and Joint Surgery, 63A(3), 380383, 1981.

Biomechanical Aspects of CTDs

3-37

Gelberman, R., Goldberg, V., and An, K.N. Tendon, in Injury and Repair of the Musculoskeletal Soft
Tissues, Woo, S.L.Y. and Buckwalter, J.A., editors, pp. 140, American Academy of Orthopaedic
Surgeons, 1988.
Goldie, I. Epicondylitis lateralis humeri (Epicondylitis of tennis elbow): A pathogenetic study. Acta Chir
Scand Suppl, 339, 1119, 1964.
Goldstein, S.A., Armstrong, T.J., Chaffin, D.B., and Matthews, L.S. Analysis of cumulative strain in
tendons and tendon sheaths. Journal of Biomechanics, 20, No. 1, 16, 1987.
Grant, K.A., Habes, D.J., and Steward, L.L. An analysis of handle designs for reducing manual effort:
The influence of grip diameter. International Journal of Industrial Ergonomics, 10, 199206, 1992.
Johnson, E.W. Practical Electromyography, 2nd edition, Williams and Wilkins, 1989.
Kerr, C., Sybert, D.R., and Albarracin, N.S. An analysis of the flexor synovium in idiopathic carpal
tunnel syndrome: Report of 625 cases. Journal of Hand Surgery, 17A(6), 10281030, 1992.
Kuorinka, I. and Forcier, L., editors. Work-Related Musculoskeletal Disorders (WMSDs): A Reference
Book for Prevention. Taylor & Francis, 1995.
Lamphier, T.A., Crooker, C., and Crooker, J.L. Industrial Medicine and Surgery, 847856, 1965.
Landsmeer, J.M.F. Power grip and precision handling. Annals Rheumatoid Diseases, 21, 164170, 1962.
LeVeau, B. Biomechanics of Human Motion. Baltimore: Williams and Lissner, 1977.
Marras, W.S. Towards an understanding of dynamic variables in ergonomics. Occupational Medicine:
State of the Art Reviews, Vol. 7, No. 4, 655677, 1992.
Marras, W.S. and Sommerich, C.M. A three-dimensional motion model of loads on the lumbar spine: I.
Model structure. Human Factors, 33(2), 123137, 1991a.
Marras, W.S. and Sommerich, C.M. A three-dimensional motion model of loads on the lumbar spine: II.
Model validation. Human Factors, 33(2), 139149, 1991b.
Merriam, J.L. and Kraige, L.G. Engineering Mechanics: Dynamics, Second edition, John Wiley & Sons, 1984.
Moore, J.S. and Garg, A. State of the art reviews: Ergonomics: low-back pain, carpal tunnel syndrome,
and upper extremity disorders in the workplace. Occupational Medicine, Vol. 7, No. 4, 1992.
Moore, A.E. A system to predict internal load factors related to the development of cumulative trauma
disorders of the carpal tunnel and extrinsic flexor musculature during grasping. Masters thesis,
University of Waterloo, Waterloo, Canada, 1988.
Moore, A., Wells, R., and Ranney, D. Quantifying exposure in occupational manual tasks with cumulative
trauma disorder potential. Ergonomics, 34, 14331453, 1991.
Nirschl, R. Muscle and tendon trauma: tennis elbow. Chapter 28 in The Elbow and Its Disorders, W.B.
Saunders Co., 1985.
Ogata, K. and Naito, M. Blood flow of peripheral nerve effects of dissection, stretching, and compression.
The Journal of Hand Surgery, 11B(1), 1014, 1986.
Paget, J. Lectures in Surgical Pathology, Philadelphia: Lindsay & Blakiston, p. 42, 1860.
Phalen, G.S. The carpal tunnel syndrome: seventeen years experience in diagnosis and treatment of six
hundred fifty-four hands. Journal of Bone and Joint Surgery, 48-A(2), 211228, 1966.
Phalen, G.S. The birth of a syndrome, or carpal tunnel revisited, Guest Editorial. Journal of Hand
Surgery, 109110,1981.
Phalen, G.S. and Kendrick, J.I. Compression neuropathy of the median nerve in the carpal tunnel,
JAMA, 164:524530, 1957.
Putz-Anderson, V., Editor. Cumulative Trauma Disorders: A Manual for Musculoskeletal Diseases of
the Upper Limbs. Taylor & Francis, 1988.
Quinnel, R.C. Conservative management of trigger finger. The Practitioner, 224, 187190, 1980.
Rasch, P.J. Kinesiology and Applied Anatomy, 7th edition, Lea and Febiger, 1989.
Rempel, D. and Horie, S. Effect of wrist posture during typing on carpal tunnel pressure, in Proceedings
of Working With Display Units: 4th International Scientific Conference, Milan, Italy, p. C27, 1994.
Rigby, B.J., Hirai, N., and Spikes, J.D. The mechanical properties of rat tail tendon. J Gen Physiol,
43:265283, 1959.
Robbins, H. Anatomical study of the median nerve in the carpal tunnel and the etiologies of carpal
tunnel syndrome. Journal of Bone and Joint Surgery, 45A, 953966, 1963.

3-38

Occupational Ergonomics: Engineering and Administrative Controls

Rowe, M.L. Orthopaedic Problems at Work, Perinton Press, 1985.

Schoenmarklin, R.W. and Marras, W.S. A dynamic biomechanical model of the wrist joint, in Proceedings
of the 34th meeting of the Human Factors Society, Orlando, FL., 805809, 1990.
Schoenmarklin, R.W. and Marras, W.S. Dynamic capabilities of the wrist joint in industrial workers,
International Journal of Industrial Ergonomics, 11, 207224, 1993.
Schoenmarklin, R.W. and Marras, W.S. An EMG-assisted biomechanical model of the wrist joint.
Advances in Industrial Ergonomics and Safety IV, edited by Kumar, S., 777781, Taylor & Francis
Publishers, 1992.
Schivde, A.J., Dreizen I., and Fisher, M.A. The carpal tunnel syndrome: A clinical-electrodiagnostic
analysis. Electromyogr Clin Neurophysiol, 21, 143153, 1981.
Schuind, P.F., Garcia-Elias, M., Cooney, W.P., and An, K.N. Flexor tendon forces: In vivo measurements.
Journal of Hand Surgery, 17A(2), 291298, 1992.
Silverstein, B.A., Fine, L.J., and Armstrong, T.J. Hand wrist cumulative trauma disorders in industry.
British Journal of Industrial Medicine, 43, 779784, 1986.
Silverstein, B.A., Fine, L.J., and Armstrong, T.J. Occupational factors and carpal tunnel syndrome.
American Journal of Industrial Medicine, 11, 343358, 1987.
Smith, E.M., Sonstegard, D.A., and Anderson, W.H. Contribution of flexor tendons to the carpal tunnel
syndrome. Archives of Physical Medicine and Medical Rehabilitation, 58, 379385, 1977.
Sommerich, C.M. Carpal tunnel pressure during typing: Effects of wrist posture and typing speed, in
Proceedings of the Human Factors and Ergonomics Society 38th Annual Meeting, 611615, 1994.
Spence, A.P. Basic Human Anatomy, Second Edition, The Benjamin/Cummings Publishing Co., 1986.
Stedman, T.L. Stedmans Medical Dictionary, 24th edition, Williams and Wilkins, 1982.
Stramler, J.H. The Dictionary for Human Factors and Ergonomics, CRC Press, 1993.
Szabo, R.M. and Gelberman, R.H. The pathophysiology of nerve entrapment syndromes. The Journal
of Hand Surgery, 12A(5), 880884, 1987.
Tanaka, S. and McGlothlin, J.D. A conceptual model to assess musculoskeletal stress of manual work for
establishment of quantitative guidelines to prevent hand and wrist cumulative trauma disorders (CTDs),
in Advances in Industrial Ergonomics and Safety I, Mital, A., editor, 419426, Taylor & Francis, 1989.
Van de Graaff, K.M. and Rhees, R.W. Human Anatomy and Physiology, Schaums Outline Series in
Biology, McGraw-Hill Book Co., 1987.
Williams, H.J. and Ward, J.R. Musculoskeletal occupational syndromes. Chapter 29 in Environmental
and Occupational Medicine, Little, Brown, & Co., 1983.
Yamaguchi, D.M., Lipscomb, P.R., and Soule, E.H. Carpal tunnel syndrome. Minn Med, 2223, Jan. 1965.

For Further Information

Although replete with medical terminology, an excellent reference for the biomechanical pathogenesis of
cumulative trauma disorders of the upper extremity are chapters on the muscle-tendon unit and
carpal tunnel syndrome in [Link] and [Link] State of the Art Reviews: Ergonomics: LowBack Pain, Carpal Tunnel Syndrome, and Upper Extremity Disorders in the Workplace.
A good discussion of biomechanical models of the wrist is presented in Section 6.5.2 of Occupational
Biomechanics, 2nd Edition by Don [Link] and Gunnar [Link]. This book also has a
chapter on handtool design (Chapter 5).
Basmajians Primary Anatomy, 8th edition provides easy-to-read and well-illustrated depictions of the
bodys soft tissues (muscles, nerves, and tendons) and their structures and functions.
The Clinical Mechanics of the Hand by Paul [Link] is particularly helpful in describing the function of
specific muscles and tendons in the hand and forearm and how these interact to configure the hand
in common pinch and grip postures.
The Work-Related Musculoskeletal Disorders (WMSDs): A Reference Book for Prevention (edited by
Kuorinka and Forcier) is an excellent book that describes specific WMSDs and provides evidence
for the association between work-related activity and each respective WMSD.

4
Occupational Risk
Factors for Shoulder
Disorders
4.1 Introduction
4.2 Structure and Function of the Shoulder

4-1
4-2

Bony Structures Muscles and Tendons Nerves and Vessels

Around the Shoulder Movements of the
Shoulder Loading of Shoulder Muscles in Different
Activities Mechanisms of Injury in the Shoulder
4.3

Eira Viikari-Juntura
Finnish Institute of Occupational
Health

Occupational Risk Factors

Heavy Physical Work Manual Handling Elevated Postures
of the Arm Nonneutral Trunk Postures Static
Work Repetitive Work Work-Rest Schedule: Lack of
Pauses Vibration Draft Work Organizational
Factors Summary of Occupational Risk Factors

4-4

4.1 Introduction
This chapter deals with occupational risk factors of shoulder disorders. The shoulder is structurally and
functionally intimately linked with the neck, and often neck-shoulder disorders have been dealt with as
one group of disorders. In this chapter, the main emphasis is on the disorders of shoulder structures,
although some overlap to the neck area cannot be avoided.
The shoulder is a complex system of bones, muscles, tendons, and ligaments that attach the upper
extremity to the torso. The glenohumeral joint is the joint with the largest range of motion in the human
body, allowing large mobility for the upper extremity and enabling the body to reach far in all directions.
The primary function of the shoulder is to direct and support the hand in its activities.
Because of its supporting function, high forces are imposed on the shoulder, especially if the
hand is holding a heavy object. Due to the long moment arm of the extended upper arm, fairly light
objects, weighing about 1 kg, impose high mechanical stress on the shoulder. To be able to withstand
such forces great stability is demanded of the structures of the shoulder. On the other hand, the long
moment arm of the upper arm and the large mobility and relatively poor protection of the shoulder
joint render various tissues liable to injuries associated with falls and other sudden movements.
Such injuries may heal only partially and decrease the strength and stability of the structures
permanently.
Physical load factors occurring at work associated with various shoulder disorders include manually
strenuous activities, postural factors of the arm and torso, static work, repetitive work, lack of rest pauses,
vibration from handheld tools, environmental factors, and work organizational factors. Only a small
amount of data exist on which to base any reference values for acceptable load intensities, frequencies, and
durations of such factors. Because of the great liability of the shoulder to acute injuries, nonoccupational

0-8493-1800-9/03/$0.00+$1.50
2003 by CRC Press LLC

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FIGURE 4.1 Bony structures in the shoulder, front view.

activities, especially hand-intensive sports, should be considered when investigating the etiology of shoulder
pain in individual workers.
Due to the complexity of the shoulder, it has long been difficult to estimate the stresses to the different
parts in the shoulder complex when exposed to various physical load factors. Recent advances in
biomechanical modeling have markedly increased our knowledge of the stresses on the different structures
of the shoulder and also of the capacity of shoulder structures.

4.2 Structure and Function of the Shoulder

Bony Structures
The most important bones in the shoulder are the shoulder blade (scapula), the humerus, and the clavicle
(Figure 4.1). The humerus is attached to the scapula by the glenohumeral joint at the lateral aspect. It is
in this joint that the primary motion occurs during movements of the arm. The clavicle is attached to the
acromion in the upper lateral aspect of the shoulder, and the other end attaches to the sternum. The
scapula covers part of the dorsal aspect of the rib cage.

Muscles and Tendons

The prime movers of the shoulder are the deltoid and four so-called rotator cuff muscles. The deltoid
has its origin at the lateral part of the clavicle, the acromion process of the scapula, and the back of the
scapula and inserts at the lateral aspect of the humerus. The rotator cuff muscles have their origin in the
scapula and insert at the head of the humerus. Before the insertion, their tendons merge around the head
of the humerus, thereby forming the rotator cuff (Figure 4.2). The trapezius is a flat muscle on the
surface that has its origin at the occiput, neck, and thoracic vertebrae and inserts at the clavicle, acromion
process of the scapula and spine of the scapula.

Occupational Risk Factors for Shoulder Disorders

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FIGURE 4.2 Insertion of rotator cuff tendons at the head of humerus, front view.

Nerves and Vessels Around the Shoulder

In addition to the nerves and vessels that supply the shoulder muscles and bones, all vessels and nerves
supplying the arm and hand pass by the shoulder, forming a neurovascular bundle at the so-called
thoracic outlet area. Due to postural factors, structural anomalies, and tight bands of the muscles at the
thoracic outlet, the course of these latter nerves and vessels may be interfered with.

Movements of the Shoulder

The upper arm has a wide range of motion in all three planes: sagittal, transversal, and horizontal. The
movement in the sagittal plane is the flexionextension movement, the movement in the transversal
plane is the abduction-adduction movement; and the movement in the horizontal plane is the horizontal
abduction and adduction (Figure 4.3). Moreover, the arm has a wide range of rotation around its
longitudinal axis. Most work activities demand varying degrees of flexion and abduction of the shoulder,
often with the forearm in flexion at the elbow.

Loading of Shoulder Muscles in Different Activities

Shoulder muscle loading may be estimated by recording the electrical activity of the muscles by
electromyography and measuring the intramuscular pressure. The trapezius, deltoid, supraspinatus, and
infraspinatus muscles have been measured most commonly. The abduction movement in the plane of the
scapula creates more loading than the flexion movement, especially for the supraspinatus muscle. The
intramuscular pressure shows a linear increase with increasing abduction or flexion angle. In the
supraspinatus, a flexion or abduction angle of 30 is enough to raise the intramuscular pressure above
the level where muscle blood flow is impeded. Adding hand load increases the intramuscular pressure
markedly. The increase is somewhat higher in shoulder abduction than in flexion. Flexing the elbow by
90 reduces the intramuscular pressure by about 30% in shoulder abduction.

Mechanisms of Injury in the Shoulder

Shoulder disorders may have their pathological process in the muscles, tendons, nerves, or joints. Commonly
painful muscles are the trapezius, especially the descending part, supra- and infraspinatus, and the levator
scapulae. Tendinitis of the rotator cuff tendons (e.g., supraspinatous or infraspinatous tendinitis) is the
most common tendon disorder at the shoulder. In the thoracic outlet syndrome, the nerves and/or vessels
of the neurovascular bundle are compressed at the thoracic outlet. The joints of the shoulder differ as to
how prone they are to degenerative changes. In the glenohumeral joint, degenerative changes are uncommon,
whereas in the acromioclavicular joint, such changes occur much more frequently.

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FIGURE 4.3 Movements of the shoulder in the three planes.

As described above, flexion and abduction of the arm increase the intramuscular pressure, which in
turn interferes with blood circulation and may produce local ischemia and cause muscle pain. Other
possible mechanisms for muscle pain are disturbances in energy metabolism and mechanical failure,
especially after heavy physical exercise.
Rotator cuff tendinitis is usually associated with degenerative changes in the tendons of the rotator
cuff. Such changes may be caused by impaired circulation in the tendon due to high tension in the
muscle. When the hand is exposed to local low-frequency vibration, the muscles of the arm contract
involuntarily as a consequence of the tonic vibration reflex. The tendons of the rotator cuff may also be
mechanically injured due to compression under the acromion and the coracoacromial arch. The tendons
may also be injured in falls and other accidents. A degenerated tendon is more likely to tear in an
accident than is a healthy tendon.

4.3 Occupational Risk Factors

Knowledge of occupational risk factors for shoulder disorders is based on epidemiological studies in the
field and experimental studies in the laboratory. Epidemiological studies have investigated the associations
between physical load factors and clinically defined shoulder tendinitis, radiographically assessed
degenerative joint disease, or reported shoulder pain. In many epidemiological studies, certain occupations
have been selected to represent a certain type of work, e.g., welders for overhead work. In some other
studies, exposure assessment has been based on self-assessment. Only rarely has the validity of such selfassessment been investigated. This means that the information on physical load factors in the
epidemiological studies is usually crude and may have considerable inaccuracy and even bias. Only
exceptionally have direct measurements been carried out.

Occupational Risk Factors for Shoulder Disorders

4-5

In experimental studies, the intensity, frequency, and duration of the exposure can be determined and
measured with high precision, but the outcome is different from that in the epidemiological studies. In
addition to subjectively assessed discomfort, various physiological responses have been measured, such as
myoelectrical activity of muscles, intramuscular pressure, and blood metabolites. Only some data exist on
the associations between different types of physiological responses and the development of shoulder disorders.
Based on epidemiological and experimental evidence, ten work-related risk factors may be recognized:

Heavy physical work

Manual handling

Elevated postures of the arm

Nonneutral trunk postures

Static postures

Repetitive work

Lack of pauses

Vibration

Draft

Work organizational factors

Each of these risk factors will be discussed below. A compilation of selected epidemiological studies
(Table 4.1), studies in which various physiological responses have been measured during real or simulated
work (Table 4.2), and studies that have measured various physiological responses during basic movements
and loading situations of the shoulder in the laboratory (Table 4.3) serve as a source of original data for
the text. In all studies, various physical load factors (exposure) have been the independent variables
under study. The outcome or health effect has usually been more long term by nature in the epidemiologic
studies and a short-term response in the experimental studies.

Heavy Physical Work

Several studies have shown an association between heavy physical work and shoulder problems. The
association has been found for shoulder tendinitis (Stenlund et al., 1993), radiographically defined
acromioclavicular arthrosis (Stenlund et al., 1992), and reported shoulder pain (Viikari-Juntura et al.,
1993). An increased risk of acromioclavicular arthrosis was observed for 10 to 28 years of manual
work, and an even higher risk for more than 28 years of manual work, i.e., an exposure-response
relationship was observed for cumulative exposure to manual work. Examples of occupational groups
are rockblasters, bricklayers, and various jobs in forestry.
Heavy physical work may involve manual handling of heavy loads, nonneutral trunk postures, and
elevated postures of the arm. Such work may also be associated with repeated minor traumas and a risk
of major trauma.

Manual Handling
Manual handling of loads has been associated with shoulder disorders in some studies. Wells et al. (1983)
found a higher prevalence (13%) of recurrent shoulder pain for letter carriers than for meter readers (7%)
and postal clerks (5%). The maximum bag weight of the letter carriers was 11.4 kg. Letter carriers whose
maximum bag weight had been increased by 4.4 kg had a prevalence of 23% of recurrent shoulder pain.
Stenlund et al. (1992) determined life-long lifting as lifted tonnes, and found an increased risk of radiographically
assessed osteoarthrosis of the acromioclavicular joint for 710 to 26,000 tonnes, and an even higher risk for
more than 26,000 tonnes. This means that an exposure-response relationship was also found for lifted load
and acromioclavicular joint arthrosis. Unfortunately, it is not known whether intensive lifting for a short
period is associated with a different risk than less intensive lifting for a longer period. It should also be noted
that the data on lifting were based on questionnaires and interviews with no assessment of validity.

TABLE 4.1 Selection of Epidemiological Studies on Shoulder Disorders

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Occupational Risk Factors for Shoulder Disorders

4-7

TABLE 4.1 (continued) Selection of Epidemiological Studies on Shoulder Disorders

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Occupational Ergonomics: Engineering and Administrative Controls

TABLE 4.2 Selected studies on Physiological Responses During Real or Simulated Work Tasks Involving Activation of Shoulder Muscles

Occupational Risk Factors for Shoulder Disorders

4-9

* Activity figures from different studies, given as % of maximal activity, can be compared only roughly, due to different calibration procedures in different studies.

TABLE 4.2 (continued) Selected studies on Physiological Responses During Real or Simulated Work Tasks Involving Activation of Shoulder Muscles

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Occupational Ergonomics: Engineering and Administrative Controls

TABLE 4.3 Selected Studies on Physiological Responses Associated with Controlled Postures and Loading of the Shoulder Muscles in the Laboratory

Occupational Risk Factors for Shoulder Disorders

4-11

* Activity figures from different studies, given as % of maximal activity, can be compared only roughly, due to different calibration procedures in different studies.

TABLE 4.3 (continued) Selected Studies on Physiological Responses Associated with Controlled Postures and Loading of the Shoulder Muscles in the Laboratory

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Occupational Risk Factors for Shoulder Disorders

4-13

Manual handling activities impose high loads on probably all shoulder structures of which the rotator
cuff muscles and the deltoid have been the most investigated (Sigholm et al., 1984; Jrvholm et al., 1988).
Hand load has a strong effect on shoulder muscle activity, especially in the rotator cuff muscles, and on
intramuscular pressure in the supraspinatus. Manual handling activities may also run a risk of trauma.

Elevated Postures of the Arm

There is some epidemiological evidence to support an association between elevated postures of the arm
and shoulder pain (Bjelle et al., 1979; Sakakibara et al., 1995) as well as supraspinatus tendinitis (Herberts
et al., 1981). The occupations involved in the studies have been shipyard welders and orchard farmers.
Experimental studies have shown that the activity of shoulder muscles increases with increasing elevation
(flexion and abduction) of the arm (Sigholm et al., 1984). A flexion angle of =30 without hand load
raises the intramuscular pressure at a level where blood circulation is disturbed (Sigholm et al., 1984;
Jrvholm et al., 1988). After longer periods of intensive shoulder muscle exercise, cardiovascular and
neuromuscular recovery may be incomplete for hours (Mathiassen, 1993). Elevated arm postures may
also be associated with mechanical irritation of the rotator cuff tendons under the acromion and
coracoacromial arch.
The loads imposed on shoulder structures in various activities with elevated arms may be decreased
by suspending the arms. The results from the simulated work of welders showed that arm suspension
reduced shoulder muscle load, but the intramuscular pressure of the supraspinatus remained at a level
where muscle blood flow would still be compromised (Jrvholm et al., 1991).

Nonneutral Trunk Postures

In sedentary work, the workplace layout largely determines the posture of the torso, neck, and limbs.
Schldt et al. (1987) investigated the myoelectrical activity of several neck and shoulder muscles in different
postures during simulated soldering work in the laboratory. Sitting with the spine slightly tilted backward
and the cervical spine vertical was associated with the lowest activity. The posture with the whole spine
straight and vertical resulted in a higher myoelectrical activity, and the posture with the whole spine flexed
was associated with the highest activity. In the latter experiment, the work object was horizontal in the
whole-spine-flexed posture, tilted 35 in the whole-spine-straight-and-vertical posture, and tilted 75 in
the posture with the spine tilted backward and neck vertical. As stated by these authors, a backward
inclination of the spine generally requires that the work object should be tilted from the horizontal plane.

Static Work
According to epidemiological studies, shipyard welders (Herberts et al., 1981), orchard harvesters
(Sakakibara et al., 1995), packers (Luopajrvi et al., 1979), garment workers (Punnett et al., 1985),
workers in light assembly tasks (Kvarnstrm, 1983), and office workers with intensive use of the mouse
(Hagberg and Karlqvist, 1994) have shown a high risk for shoulder disorders. Common to the tasks in
these occupations is static exertion of shoulder muscles with or without elevation of the arm.
Measurements of myoelectrical activity in the field and simulated work in the laboratory have shown
static activity levels ranging from 4 to 17% of maximal activity in different shoulder muscles (Christensen,
1986; Sundelin and Hagberg, 1992), the upper range being far above the 2 to 5% of maximal activity
recommended by Jonsson (Jonsson, 1982). A simulation of cash register operation in the laboratory
(Lannersten and Harms-Ringdahl, 1990) and word processing operations, both with spontaneous and
forced pauses (Hagberg and Sundelin, 1986), was associated with a lower static load of 2 to 5% of
maximal activity.
Measurements of various keyboard activities in the field showed activity in the trapezius also at times
when no activity was performed by the forearm (Onishi et al., 1982). The importance of interruptions
of activity was shown in a follow-up of workers at a chocolate manufacturing plant. The workers who

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Occupational Ergonomics: Engineering and Administrative Controls

had a smaller number of short unconscious interruptions of electromyographic activity (so-called emggaps) had a higher risk of contracting trapezius myalgia than those with a higher number of emg-gaps
during a follow-up time of six months (Veiersted et al., 1993).
The load of the shoulder muscles may be reduced by arm support or arm suspension in activities
involving static exertion of shoulder and arm muscles. A laboratory experiment of simulated soldering
work in different postures of the trunk and neck suggested that arm suspension might be more efficient
than arm support in the posture with the trunk slightly inclined backward. Arm support might be more
effective than arm suspension in the whole-spine-flexed posture. This latter posture, however, showed
generally high myoelectrical activities and should not be adopted for longer periods of work (Schldt et
al., 1987).

Repetitive Work
A typical pattern of repetitive work is that the fingers perform quick movements while the shoulder
muscles perform mostly static exertions to fulfil their primary task in supporting the arms. Word
processing, packing, and light assembly tasks are examples of such repetitive work, and high risk for
shoulder disorders has been shown in these tasks. In a simulation of assembly work in the laboratory,
the introduction of a one-minute pause with dynamic lifting activity every 6th minute resulted in less
pronounced myoelectrical signs of fatigue in the shoulder muscles, suggesting that dynamic activity
might be effective in counteracting the effects of static loading of shoulder muscles (Sundelin, 1993). No
difference was seen in discomfort ratings, however.
Certain work tasks may demand repetitive movements of the upper arm, but the health effects of
repetitive arm flexions or abductions are not well known. In an experimental study in which six healthy
students performed repetitive shoulder flexions with a frequency of 15/min for 60 minutes with loads
varying from 0 to 3.1 kg, all subjects had tenderness in the descending part of the trapezius and
supraspinatus, and two of them also had other signs of supraspinatus tendinitis after two days (Hagberg,
1981). A study among electronics assembly workers showed that the duration of mild upper arm flexion
was associated with shoulder disorders, but the number of upper arm flexions was inversely related to
shoulder disorders (Kilbom et al., 1986). This suggests that a more dynamic working style decreases the
risk of shoulder disorders.
An experimental study used the psychophysical approach to investigate the effects of various repetition
rates, forces, tool weights, and reach heights on work durations until a given degree of subjectively rated
fatigue was achieved in repeated arm flexions. The repetition rate was the prime determinant for work
duration, followed by force, height of upper target, and tool weight. Repetition rate and force showed
an interaction, so that increases in each variable led to a slight attenuation of the other variables effect
(Putz-Anderson and Galinsky, 1993). This study is among the few sources of data on which reference
values for the frequencies of shoulder elevations with given loads and elevation angles may be established.

Work-Rest Schedule: Lack of Pauses

It is conceivable that the frequency, duration, and quality of pauses are crucial determinants for the
development of fatigue in the muscles during forceful, repetitive, or static exertions. Work-rest schedules
have been investigated in some studies in the field (Hagberg and Sundelin, 1986) and in the laboratory.
In the aforementioned simulation of light industrial work in the laboratory, an MTM-110 pacing without
pauses was compared with an MTM-132 pacing with one-minute pause every 6th minute, consisting of
the dynamic lifting activity, the production rate of the task itself being equal in both schemes. As mentioned,
electromyographic signs of fatigue were less pronounced with pause activities than without, despite the
higher repetition rate and extra work of lifting during the pauses (Sundelin, 1993). In another experimental
study, a range of physiological responses was measured when holding the arm continuously and
intermittently in the horizontal plane at 60 to the sagittal plane. Duty cycle had a more pronounced
effect on the various physiological responses than cycle time. A ranking of the protocols with different

Occupational Risk Factors for Shoulder Disorders

4-15

combinations of cycle time and duty cycle differed according to which physiological response was used
(Mathiassen, 1993).
In conclusion, while the need for pauses is evident in tasks demanding forceful, repetitive, or static
shoulder activities, only few data exist upon which to base any recommendation. Moreover, the
recommendations will differ depending on what kind of physiological criterion is used. Sometimes
objective and subjective criteria seem to contradict each other.

Vibration
Vibration from hand-held tools has been shown to be associated with both radiographically assessed
arthrosis of the acromioclavicular joint (Stenlund et al., 1992) and shoulder tendinitis (Stenlund et al.,
1993). For both conditions, an exposure-response relationship between cumulative exposure to vibration
and the disease have been observed. The assessment of cumulative exposure took into consideration the
hours that each vibrating tool had been used and the energy emission from the tool.

Draft
High air velocities in the work environment are perceived as draft and traditionally considered to increase
neck and shoulder discomfort. Only some epidemiological evidence exists for the association of draft
with neck and shoulder pain (Tola et al., 1988). The behavior of shoulder muscles was studied in an
experiment with different air velocities in the office environment. The myoelectrical activity changes
suggested increased recruitment of motor units in some muscles, and a possible cooling effect in others
associated with increasing air velocity (Sundelin and Hagberg, 1992).

Work Organizational Factors

Demands, control, and social support are work organizational factors that have been most often
investigated in association with shoulder disorders. An association between high job demands such as
time pressure, high concentration, high work load and shoulder disorders has been shown in many
studies. Also low control and little autonomy has been associated with shoulder disorders, but the
results concerning social support are conflicting (Bongers et al., 1993). In a follow-up study, mental
overload (difficult phases at work, the need to hurry to get work done) was associated with the persistence
of severe shoulder pain but not with the incidence of pain, indicating that work organizational factors
might have a greater role in the prognosis than in the genesis of shoulder disorders (Viikari-Juntura et
al., 1993).

Summary of Occupational Risk Factors

The text above deals with individual occupational risk factors for shoulder disorders. In real work
situations, many risk factors are present simultaneously and may have combined effects on the risk of
shoulder disorders. In dynamic work, the overall risk of shoulder disorders is probably a function of
arm posture, weight of load, and frequency of repetitions of arm movements. There is evidence that a
high cumulative exposure of heavy work increases the risk of shoulder disorders, but whether a certain
duration of heavy work per day could be tolerated for longer times is not known. Traumas to the
shoulder may increase the risk of shoulder disorders in heavy work. There is convincing evidence of
harmful effects of low-frequency vibration from handheld tools to the shoulder. Therefore, low-frequency
vibration from tools should be eliminated or kept to the minimum.
In static work tasks with lower force demands, the elevation angle of the arm, the overall posture of
the body, and the rest pauses largely determine the loading pattern of shoulder muscles. In this kind of
work, optimal body and arm postures should be enabled by proper workplace layout and possibilities
to support or suspend the arm according to the preference of the worker.

4-16

Occupational Ergonomics: Engineering and Administrative Controls

Work organizational factors may have an effect on the risk of shoulder disorders by influencing the
intensity, frequency, or duration of physical load factors. They may also affect the reporting of the
disorders or the recovery from them.

References
Bjelle, A., Hagberg, M., and Michaelsson, G. 1979. Clinical and ergonomic factors in prolonged shoulder
pain among industrial workers. Scand. J. Work Environ. Health 5(3):205210.
Bongers, P.M., De Winter, C., Kompier, M.A.J., and Hildebrandt, V.H. 1993. Psychosocial factors at
work and musculoskeletal disease. Scand. J. Work Environ. Health 19(5):297312.
Christensen, H. 1986. Muscle activity and fatigue in the shoulder muscles of assembly-plant employees.
Scand. J. Work Environ. Health 12(6):582587.
Hagberg, M. 1981. Work load and fatigue in repetitive arm elevations. Ergonomics 24(7):543555.
Hagberg, M. and Karlqvist, L. 1994. Symptoms and disorders related to keyboard and computer mouse
use. International Conference on Occupational Disorders of the Upper Extremities, December 12,
1994, Miyako Hotel, San Francisco, California.
Hagberg, M. and Sundelin, G. 1986. Discomfort and load on the upper trapezius muscle when operating
a wordprocessor. Ergonomics 29(12): 16371645.
Herberts, P., Kadefors, R., Andersson, G., and Petersn, I. 1981. Shoulder pain in industry: An
epidemiological study on welders. Acta Orthop. Scand. 52(3):299306.
Jonsson, B. 1982. Measurement and evaluation of local muscular strain in the shoulder during constrained
work. J. Human Ergol. 11(1):7388.
Jrvholm U., Palmerud, G., Kadefors, R., and Herberts, P. 1991. The effect of arm support on the
supraspinatus muscle during simulated assembly work and welding. Ergonomics 34(1):5766.
Jrvholm, U., Palmerud, G., Styf, J., Herberts, P., and Kadefors, R. 1988. Intramuscular pressure in the
supraspinatus muscle. J. Orthop. Res. 6(2):230238.
Kilbom, A., Persson, J., and Jonsson, B.G. 1986. Disorders of the cervicobrachial region among female
workers in the electronics industry. Int. J. Ind. Ergonomics 1(1):3747.
Kvarnstrm, S. 1983. Occurrence of musculoskeletal disorders in a manufacturing industry, with special
attention to occupational shoulder disorders. Scand. J. Rehab. Med. (Suppl. 8):6101.
Lannersten, L. and Harms-Ringdahl, K. 1990. Neck and shoulder muscle activity during work with
different cash register systems. Ergonomics 33(1):4965.
Luopajrvi, T., Kuorinka, I., Virolainen, M., and Holmberg, M. 1979. Prevalence of tenosynovitis and
other injuries of the upper extremities in repetitive work. Scand. J. Work Environ. Health 5(Suppl.
3):4855.
Mathiassen, S.-E. 1993. The influence of exercise/rest schedule on the physiological and psychophysical
response to isometric shoulder-neck exercise. Eur. J. Appl. Physiol. 67(6):528539.
Onishi, N., Sakai, K., and Kogi, K. 1982. Arm and shoulder muscle load in various keyboard operating
jobs of women. J. Human Ergol. 11(1):8997.
Punnett, L., Robins, J.M., Wegman, D.H., and Keyserling, W.M. 1985. Soft tissue disorders in the upper
limbs of female garment workers. Scand. J. Work Environ. Health 11(6):417425.
Putz-Anderson, V. and Galinsky, T.L. Psychophysically determined work durations for limiting shoulder
girdle fatigue from elevated manual work. Int. J. Ind. Ergon. 11(1):1928.
Sakakibara, H., Miyao, M., Kondo, T., and Yamada, S. 1995. Overhead work and shoulder-neck pain
in orchard farmers harvesting pears and apples. Ergonomics 38(4):700706.
Schldt, K., Ekholm, J., Harms-Ringdahl, K., Nmeth, G., and Arborelius, U.P. 1986. Effects of changes
in sitting work posture on static neck and shoulder muscle activity. Ergonomics 29(12):15251537.
Schldt, K., Ekholm, J., Harms-Ringdahl, K., Nmeth, G., and Arborelius, U.P. 1987. Effects of arm
support or suspension on neck and shoulder muscle activity during sedentary work. Scand. J. Rehab.
Med. 19(2):7784.

Occupational Risk Factors for Shoulder Disorders

4-17

Sigholm, G., Herberts, P., Almstrm, C., and Kadefors, R. 1984. Electromyographic analysis of shoulder
muscle load. J. Orthop. Res. 1(4):379386.
Stenlund, B., Goldie, I., Hagberg, M., and Hogstedt, C. 1993. Shoulder tendinitis and its relation to
heavy manual work and exposure to vibration. Scand. J. Work Environ. Health 19(1):4349.
Stenlund, B., Goldie, I., Hagberg, M., Hogstedt, C., and Marions, O. 1992. Radiographic osteoarthrosis
in the acromioclavicular joint resulting from manual work or exposure to vibration. Br. J. Ind. Med.
49(8):588593.
Sundelin, G. 1993. Patterns of electromyographic shoulder muscle fatigue during MTM-paced repetitive
arm work with and without pauses. Int. Arch. Occup. Environ. Health 64(7):485493.
Sundelin, G. and Hagberg, M. 1992. Electromyographic signs of shoulder muscle fatigue in repetitive
arm work paced by the Methods-Time-Measurement system. Scand. J. Work Environ. Health
18(4):262268.
Sundelin, G., and Hagberg, M. Effects of exposure to excessive drafts on myoelectric activity in shoulder
muscles. J. Electromyogr. Kinesiol. 2:3641.
Tola, S., Riihimki, H., Videman, T., Viikari-Juntura, E., and Hnninen, K. 1988. Neck and shoulder
symptoms among men in machine operating, dynamic physical work and sedentary work. Scand. J.
Work Environ. Health 14(5):299305.
Veiersted, K.B., Westgaard, R., and Andersen, P. 1993. Electromyographic evaluation of muscular work
pattern as a predictor of trapezius myalgia. Scand. J. Work Environ. Health 19:284290.
Viikari-Juntura, E., Riihimki, H., Takala, E.-P., Rauas, S., Leppnen, A., Malmivaara, A., Grnqvist,
R., Hrm, M., Martikainen, R., Saarenmaa, K., and Kuosma, E. 1993. Niska-hartiaseudun ja
ylraajan oireita ennustavat tekijt metsteollisuudessa (Factors predicting pain in the neck, shoulders,
and upper limbs in forestry work). Ty ja ihminen 7(4):233253 (in Finnish with English summary).
Wells, J.A., Zipp, J.F., Schuette, P.T., and McEleney, J. 1983. Musculoskeletal disorders among letter
carriers A comparison of weight carrying, walking & sedentary occupations. J. Occup. Med.
25(11):814820.

For Further Information

A recent scientific review on occupational risk factors of soft tissue disorders of the shoulder is presented
by Sommerich, McGlothlin, and Marras in Ergonomics (1993, 36:697717).
An extensive overview of the work-relatedness of shoulder disorders as well as other disorders of the
neck and upper limbs with a practical approach to prevention is presented in Hagberg, Silverstein, Wells
et al.s Work-Related Musculoskeletal Disorders (WMSDs): A Handbook for Prevention, Taylor &
Francis, 1995.
Results on extensive investigations using electromyographic recordings in simulated sedentary work
in different postures have been presented in a supplement (No. 19, 1988) of Scandinavian Journal of
Rehabilitation Medicine by Kristina Schldt On Neck Muscle Activity and Load Reduction in Sitting
Postures.
Basic biomechanics of the shoulder are included in Occupational Biomechanics by Chaffin and
Andersson (John Wiley & Sons, Inc., 1991).

5
Hand Tools:
Design and Evaluation

Robert [Link]
University of Wisconsin-Madison

5.1
5.2
5.3
5.4
5.5
5.6

Introduction
Power Tool Triggers and Grip Force
Handle Size and Grip Force
Static Hand Force
Dynamic Reaction Force
Vibration

5-1
5-2
5-3
5-5
5-8
5-11

5.1 Introduction
This chapter describes specific hand tool design features that help minimize physical stress and maximize
task performance in jobs involving the continuous or repetitive use of hand tools. An important objective
of ergonomics in the design, selection, installation, and use of hand tools is the reduction of muscle
fatigue onset and the prevention of musculoskeletal disorders of the upper limb. It is not just the tool
design, but how a tool is used for a specific task and workstation that imparts physical stress upon the
tool operator. Consequently, there is no ergonomic hand tool per se. What makes sense in one situation
can produce unnecessary stress in another.
It is generally agreed that physical stress, fatigue, and musculoskeletal disorders can be reduced and
prevented by selecting the proper tool for the task. Tools used so that physical stress factors are minimized,
such as reducing stress concentrations in the fingers and hands, producing low force demands on the
operator, or minimizing shock, recoil, and vibration are usually the best tools for the job. Control of
these factors depends on the tool and the specific tool application. Selection of tools should, therefore,
be viewed within the context of the specific job being performed.
Tool selection should be based on (1) process engineering requirements, (2) human operator limitations,
and (3) workstation and task factors. Some factors considered for each of these requirements are
summarized in Table 5.1. A detailed description of each of these factors is contained in Radwin and
Haney (1996). Manufacturing engineers often specify the process requirements with little regard for the
operator and the workstation. Hand tool selection should therefore consider how the particular task
and workstation relate to the capabilities and limitations of the human operator for a particular tool
design. The process is not always simple and often involves an iterative approach, considering individual
tool design features and their role in augmenting and mitigating physical stress. This chapter will describe
some hand tool design features and the research leading to an understanding of how tool design can
help reduce physical stress in hand tool operation.

0-8493-1800-9/03/$0.00+$1.50
2003 by CRC Press LLC

5-1

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Occupational Ergonomics: Engineering and Administrative Controls

TABLE 5.1 Requirements for Ergonomic Hand Tool Selection

5.2 Power Tool Triggers and Grip Force

Extended-length triggers (see Figure 5.1) that distribute force among two or more fingers are often
suggested for minimizing stress concentrations at the volar aspects of the fingers (Lindquist et al., 1986;
Putz-Anderson, 1988). The rationale is that the force for squeezing the trigger and grasping the handle
will be distributed among several fingers to reduce the stress in the index finger. Following is a description
of a study that investigated how this particular design feature affects the force in the hands.
In order to directly measure finger and hand force exerted during actual tool operation, an apparatus
was constructed for simulating a functioning pistol grip pneumatic nutrunner (Oh and Radwin, 1993).
Strain gages were installed in two aluminum bars that were used as the handle for measuring force
exerted against the fingers and palm. The instrumented bars were constructed so they were insensitive to
the point of force application and linearly summed force applied along the length of the handle (Pronk
and Niesing, 1981; Radwin et al., 1991). This was accomplished by measuring shearing stress acting in
the cross section of the beam. Strain gages were mounted on a thin web that was machined into the
central longitudinal plane and aligned at 45 with respect to the long axis. The effect of bending stresses
were completely removed from the strain gages by selecting a measurement point at the neutral axis of
the beam, so that all the strain at the measurement point is strictly due to shear stress. Shear strain is
totally independent of the point of application.
The strain gage instrumented handle was mounted on a rigid frame and attached perpendicular to a
modified in-line pneumatic nutrunner motor in a configuration resembling a pistol-grip power tool (see
Figure 5.2). The two dynamometers were mounted in parallel on a track so the handle span could be
continuously adjusted. The apparatus was completely functional. The air motor contained an automatic
air shut-off torque control mechanism and was operated at a 6.8 Nm target torque setting.

FIGURE 5.1 A conventional trigger and an extended-length trigger on pistol grip power hand tools. (Reprinted with
permission from Human Factors, 35, 3, 1993. Copyright 1993 by the Human Factors and Ergonomics Society.)

Hand Tools: Design and Evaluation

5-3

FIGURE 5.2 Dynamometer used for measuring finger and palm forces exerted when operating a completely functional
simulation of a pistol-grip pneumatic power hand tool. (Reprinted with permission from Human Factors, 35, 3,
1993. Copyright 1993 by the Human Factors and Ergonomics Society.)

Plastic caps were formed and attached to each end of the dynamometer so the contours resembled a
power tool handle. The handle circumference was 12 cm for a 4-cm span, measured between two points
tangent to the handle contact surfaces. The handle circumference increased an additional 2 cm as the
handle span was increased by 1 cm. A trigger was mounted on the finger side cap (see Figure 5.2), and
a contact switch was installed inside the trigger. A leaf spring was used for controlling trigger tension.
When the trigger was squeezed, the switch tripped a relay and a solenoid valve for supplying air to the
pneumatic power tool motor.
Two different trigger types were tested. One was a conventional power tool trigger, activated using
only the index finger. The second was longer than the conventional trigger and was activated using both
the index and middle fingers (see Figure 5.1). The conventional trigger was 21 mm long and the extended
trigger was 48 mm long. The conventional trigger required 8 N, and the extended trigger required 11 N
for activation.
Use of the extended trigger was found beneficial for reducing grip force and exertion levels during
tool operation. Average peak finger and palm forces were, respectively, 9% and 8% less for the extended
trigger than for the conventional trigger. Eleven of eighteen subjects (61%) indicated that they preferred
using the handle with the extended trigger after just an hour of use in the laboratory. The average finger
and palmar holding force was 65% and 48%, respectively, less for the extended trigger, than for the
conventional trigger. Since subjects spent 65% to 76% of the operating time holding the tool, using an
extended trigger may have an important effect on reducing exposure to forceful exertions in the hand
during power hand tool operation.

5.3 Handle Size and Grip Force

Research on handle design has typically focused on finding the optimal handle dimensions. Grip strength
is affected through the biomechanics of grip from the relative position of the joints of the hand and by
the position and length of the muscles involved. Consequently, grip strength is affected by the handle
size. Recommendations for handle size are usually based on the span that maximizes grip strength, or
the span that minimizes fatigue.
Hertzberg (1955), in an early Air Force study, reported that a handle span of 6.4 cm maximized
power grip strength. Greenberg and Chaffin (1975) recommended that a tool handle span should be in
the range between 6.4 cm and 8.9 cm in order to achieve high grip forces. Ayoub and Lo Presti (1971)
found that a 3.8 cm diameter was optimum for a cylindrical handle. This was based on maximizing the
ratio between strength and EMG activity, and on the number of work cycles before onset of fatigue.
Another study by Petrofsky et al. (1980) showed that the greatest grip strength occurred at a handle
span between 5 cm and 6 cm.
Grip strength is affected by hand size. Fitzhugh (1973) showed that the handle span resulting in
maximum grip strength for a 95 percentile male hand length is larger than the handle span for a 50

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Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 5.3 Average grip strength plotted against handle span for three hand size categories. Error bars represent
standard error of the mean. (Reprinted with permission from Human Factors, 35, 3, 1993. Copyright 1993 by the
Human Factors and Ergonomics Society.)

percentile female. Consequently, a person with a small hand might benefit from using a smaller handle,
and a person with a large hand might benefit from using a larger one.
Grip strength data often used for handle design are based on population measurements made using
instruments like the Jamar or Smedley dynamometers (Schmidt and Toews, 1970; Young et al., 1989) rather
than using handle dimensions representative of an actual tool. In most cases, only one dimension (handle
span) has been controlled, while the other handle dimensions were not necessarily similar to a tool handle.
A power hand tool manufacturer considered offering a power hand tool that provided a handle that
was adjustable in size. An investigation of grip strength using handle dimensions similar to power hand
tool handles was conducted in order to explore the differences against published grip strength data (Oh
and Radwin, 1993). Hand length up to 17 cm was classified as small, between 17 cm and 19 cm as
medium, and greater than 19 cm as large. Average grip strength is plotted against handle span and hand
size in Figure 5.3. Grip strength increased as hand length increased. Large hand subjects produced their
maximum grip strength (mean = 463 N, SD = 128 N) for a handle span of 6 cm, while medium hand
(mean = 280 N, SD = 122 N) and small hand (mean = 203 N, SD = 51 N) subjects produced their
maximum strength for a handle span of 5 cm.
The span resulting in maximum grip strength agreed with the findings of previous strength studies.
Hertzberg (1955) found that subjects exerted more force at a 6.4 cm span than among 3.8 cm, 6.4 cm,
10.2 cm, and 12.7 cm handle spans. Petrofsky et al. (1980) reported that on the average, subjects
produced maximum grip force for a handle span between 5 cm and 6 cm.
Although the span resulting in maximum grip strength and the grip strength function agreed with
previous findings, the maximum grip strength for both student and industrial worker subjects was
markedly less than what has been previously reported in the literature. Schmidt and Toews (1970)
collected grip strength data from 1,128 male and 80 female Kaiser Steel Corporation employee applicants,
using a Jamar dynamometer. They reported for a handle span of 3.8 cm, an average of 499 N for the
dominant male hand and 308 N for the dominant female hand. Swanson et al. (1970) measured the grip
strength of 50 females and 50 males using a Jamar dynamometer. Among these subjects, 36 were light
manual workers, 16 were sedentary workers, and 48 were manual workers. They reported for a handle
span of 6.4 cm, 467 N for the male dominant hand and 241 N for the female dominant hand. These all
exceeded the strength levels observed (see Figure 5.3).
A major difference between grip strength measured for tool handles by Oh and Radwin (1993) and
previously reported strength data is in the handle dimensions. The Jamar and Smedely dynamometers have
smaller circumferences and narrower widths than the tool handle used in this study. The tool handle curvature
was also straight while the Jamar dynamometer has a curved surface at the grip center. The handle used in this
study closely represented an actual tool handle in circumference and width. These size and curvature differences

Hand Tools: Design and Evaluation

5-5

FIGURE 5.4 Preferred handle span plotted against hand length. (Reprinted with permission from Human Factors,
35, 3, 1993. Copyright 1993 by the Human Factors and Ergonomics Society.)

can affect the position of the fingers and grip posture. These dimensional differences must be considered
when designing handles based on strength using published grip strength data.
The investigation also found a difference in grip strength between student subjects and industrial
workers. Grip strength, averaged over handle span, was 279 N (SD = 133 N) for the students and 327
N (SD = 90 N) for the workers. No significant grip strength differences, however, between the student
and worker groups were observed within each hand size.
The underlying assumption in designing handles based on maximum strength is that the actual force
exerted is independent of handle size. Exertion level is the ratio of the actual grip force used, to the
maximum voluntary force generating capacity. If the grip force used during tool operation is the same
for all handle sizes, then the handle span associated with the greatest grip strength should result in the
lowest exertion level. If grip force, however is affected by handle size, then the handle span associated
with the greatest grip strength may not be the handle span resulting in the minimum exertion level.
A series of experiments were performed using the pistol grip power hand tool with strain gage
instrumented handles and an adjustable handle span as described above. Handle span affected peak finger
and palmar force. Peak finger force increased 24% for a student subject group, and 30% for an industrial
worker group, as handle span increased from 4 cm to 7 cm. Similarly, peak palmar force increased 21% for
the student group and 22% for the worker group, as handle span increased from 4 cm to 7 cm. Handle
span also influenced finger and palmar holding forces. Finger holding force increased 20%, and palmar
holding force increased 16%, as handle span increased from 4 cm to 7 cm for the student subjects.
The study found that hand size was proportional to the handle span operators preferred when offered
the opportunity to adjust the handle size to any size they desired. Operators with larger hand sizes
reported they preferred using a tool with a larger handle. Preferred handle span is plotted against hand
length in Figure 5.4 for both trigger types. There was no difference between the preferred handle span
for the conventional trigger and the preferred handle span for the extended trigger. No anthropometric
measurements, however, were related to the span resulting in the minimum peak exertion level. Exertion
level when holding the tool was less for the large size hands than for the small size hands. Holding
exertion level for the large hands was maximum for the 4 cm handle span, while holding exertion level
for the small hands was maximum for the 7 cm handle span. In addition, the tendency for large hand
subjects to prefer larger handle spans suggests that selectable size handles may be more desirable than
having only a single size handle for power hand tools.

5.4 Static Hand Force

Safe power hand tool operation requires that an operator possess the ability to adequately support the
tool in a particular position, apply the necessary forces, while reacting against the forces generated by

5-6

Occupational Ergonomics: Engineering and Administrative Controls

the tool. Force demands that exceed an operators strength capabilities can cause loss of control, resulting
in an accident or an injury. Design and selection of power hand tools that minimize static grip and hand
force will help reduce muscle fatigue and prevent upper limb disorders.
The force necessary for supporting a power hand tool depends on the tool weight, its center of
gravity, the length of the tool, and air hose attachments. Power hand tools should be well balanced with
all attachments installed. As a general rule, a hand tool center of gravity should be aligned with the
center of the grasping hand so the hand does not have to overcome moments that cause the tool to rotate
the operators wrist and arm (Greenberg and Chaffin, 1977).
Psychophysical experiments have provided some insight into the load that power tool operators
prefer. When experienced hand tool operators were asked to rate the mass of the power tools they
operated, tools weighing 0.9 to 1.75 kg mass were rated just right (Armstrong et al. 1989). Other
psychophysical experiments showed that perceived exertion for a tool mass of 1 kg was significantly less
than for tools with a mass of 2 kg and 3 kg (Ulin and Armstrong, 1992).
There is a tradeoff between selecting a light tool and the benefit of the added weight for performing
operations that require high feed force. The power available for a grinding task increases with increasing
mass of the grinder. Reducing the weight of the grinder can increase the feed force the operator must
provide and may increase the amount of time necessary for accomplishing the task, consequently subjecting
the operator to more stressful work and greater vibration exposure. Heavy grinding tasks should be
performed on horizontal surfaces so the weight of the tool does not have to be supported by the operator.
Heavy power tools should be suspended using counterbalancing accessories.
In addition to supporting the tool load, power hand tool operators often have to exert push or feed
force, or act against reaction forces. Feed force is necessary for starting a threaded fastener, advancing a
bit, or keeping a bit or socket engaged during the securing cycle. Feed force is affected by the work
material and design of the tool, bit, or fastener. Large feed forces are sometimes needed when operating
power tools such as drills and screwdrivers. Repetitive or sustained exertions associated with these
operations should be minimized. Drill feed force is affected by the drill power and speed, bit type,
material, and diameter of the hole drilled. Power screwdriver feed force may be affected by the fastener
head and screw tip used. Feed force for a slotted or Phillips head screw generally requires more feed
force than for a torx head screw. Self-tapping screws require more force than screws tightened through
pre-tapped holes. Material hardness is also a factor for self-tapping screws and drilling. Feed force
requirements also increase as torque level increases for cross recess screws.
Power hand tools such as screwdrivers or nutrunners, used for tightening threaded fasteners, are
commonly configured as (1) in-line, (2) pistol grip, and (3) right angle. A mechanical model of a nutrunner
was developed for static equilibrium (no movement) conditions (Radwin et al., 1995). Hand force,
reaction force from the workpiece, tool orientation, weight, and output torque were included in this
model. This chapter will describe the model developed for pistol grip nutrunners.
The model uses a Cartesian coordinate system relative to the orientation of the handle grasped in the
hand using a power grip. This coordinate system has the x-axis perpendicular to the axial direction of
the handle; the y-axis is parallel to the long axis of the handle; and the z-axis is parallel to the tool
spindle. The origin is the end of the tool bit or socket. Hand forces are described in relation to these
coordinate axes. To simplify the model, an initial assumption is that orthogonal forces can be applied
along the handle without producing coupling moments. This assumption allows force to be considered
as having a single point of application. The resultant hand force FH at the grip center is the vector sum
of the three orthogonal force components
(5.1)
where the hand force magnitude is:
(5.2)

Hand Tools: Design and Evaluation

5-7

FIGURE 5.5 Free body diagram and orthogonal force components considered in the pistol grip force model.

FIGURE 5.6 Power hand tool geometry and variables in the hand tool static force model.

and i, j, k are the unit vectors. The coordinates and respective force components are illustrated
inFigure 5.5.
Consider the free-body diagram for the pistol grip nutrunner in Figure 5.6. The torque, Ts, acts in
reaction to torque, T, applied by the tool to the fastener. The tool operator has to oppose this equal and
opposite reaction torque in the counter-clockwise direction by producing a reaction force, FHx. That is
not the only force, however, that the operator has to produce. A force acting in the z direction, FHz,
provides feed force and produces an equal and opposite reaction force, FRz. In addition, the operator has
to react against the tool weight in order to support and position the tool by providing a vertical force
component, FHy. The tool weight, WT, and push force, FHz, tend to produce a clockwise moment about
the tool spindle in the yz-plane which is countered by this vertical support force.
When a body is in static equilibrium, the sum of the external forces and the sum of the moments are
equal to zero. Using that relationship, the following system of equations was developed for the pistolgrip nutrunner to describe these static forces:

(5.3)

5-8

Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 5.7 Comparison of predicted hand forces for four different tool configurations performing the same task
for one-hand tool operation.

Assuming one-hand operation, resultant hand force magnitude was predicted using the model for the
four different tools and plotted as a function of torque in Figure 5.7. Hand force was determined for
both low feed force (1 N) and high feed force (50 N) conditions, when operating these tools against a
vertical surface. When feed force was small, the resultant hand force was mostly affected by torque
reaction force, which increased as torque increased for all four tools. Since the greatest force component
in this case was torque reaction force, Tools 3 and 4 had the least resultant hand force since they both
had the longest handles. Tool 3, however, had a considerably greater resultant hand force when feed
force was high. This effect was not observed for Tool 4, which also had a similar handle, but contained
a spindle extension shaft.

5.5 Dynamic Reaction Force

Whereas manual hand tools rely on the human operator for generating forces, power hand tools operate
from an external energy source (i.e., electric, pneumatic, and hydraulic) for doing work. The tool operator
provides static force for supporting the tool and for producing feed force, and must react against the forces
generated by the power hand tool. Power hand tools such as nutrunners produce rapidly building torque
reaction forces which the operator must react against in order to maintain full control of the tool.
Nutrunner reaction torque is produced by spindle rotation and is affected primarily by the spindle
torque output and tool size. Nutrunner spindle torque can range from less than 0.8 Newton-meters
(Nm) to more than 700 Nm. This torque is transmitted to the operator as a reaction force through the
moment arm created by the tool and tool handle. A tool operator opposes reaction torque while supporting
the tool and preventing it from losing control.
The three major operating modes for nutrunners include (1) mechanical clutch, (2) stall, or (3)
automatic shut-off. When a stall tool is used, maximum reaction torque time is directly under operator
control by releasing the throttle, which can last as long as several seconds. Stall tools tend to expose an
operator to reaction torque the longest. Although clutch tools limit reaction torque exposure, ratcheting
clutch tools can expose workers to significant levels of vibration if used frequently (Radwin and Armstrong,
1985). The speed of the shut-off mechanism controls exposure to peak reaction force for automatic
shut-off tools. Consequently, automatic shut-off tools have the shortest torque reaction time because
these tools cease operating immediately after the desired peak torque is achieved.
As torque is applied to a threaded fastener, it rotates at a relatively low spindle torque until the
clamped pieces come into intimate contact. This torque can approach zero with free running nuts or can
be rather significant as in the case where locking nuts, thread interference bolts, or thread-forming type

Hand Tools: Design and Evaluation

5-9

fasteners are used. After the fastener brings the clamped members of the joint into initial intimate contact,
it continues to draw the parts together until they form a solid joint. When the joint becomes solid,
continued turning of the nut results in a proportionally increasing torque. This is the elastic portion of
the cycle and is the time when reaction torque forces are produced. Torque build-up, and consequently
torque reaction force, continues rising at a fixed rate until peak torque is achieved, which is the clamping
force of the joint. Forearm muscle reflex responses when operating automatic air shut-off right angle
nutrunners during the torque-reaction phase was more than four times greater than the muscle activity
used for holding the tool and two times greater than the run-down phase (Radwin et al., 1989). Flexor
EMG activity during the torque-reaction phase increased for tools having increasing peak spindle torque.
Threaded fastener joints are classified as soft or hard depending on the relationship between
torque build-up and spindle angle. The International Standardization Organization (ISO) specifies that
a hard joint has an angular displacement less than 30 degrees when torque increases from 50% to 100%
of target torque, and a soft joint has an angular displacement greater than 360 degrees (ISO-6544).
Nutrunner torque reaction force is a function of several factors including target torque, spindle speed,
joint hardness, and torque build-up time. Some of these factors are interdependent. Faster spindle speed
results in shorter torque build-up time, and softer joints are related to longer build-up times. The duration
of exertion is directly related to torque build-up time rather than just the speed of the tool or joint hardness.
Studies have shown that torque build-up time as well as the magnitude of torque reaction force has
a significant influence on human operators during power nutrunner use. Kihlberg et al. (1995) studied
right angle nutrunners having different shut-off mechanisms (fast, slow, and delayed) and found a strong
correlation between perceived discomfort, handle displacement, and reaction forces. Radwin et al. (1989)
investigated the effects of target torque and torque build-up time using right-angle pneumatic nutrunners
and found that average flexor rms electromyography (EMG) activity scaled for grip force increased
from 372 N for a low target torque (30 Nm) to 449 N for a high target torque (100 Nm), and that
average grip force was 390 N for a long build-up time (2 s), and increased to 440 N for a medium buildup time (0.5 s). They also reported that EMG latency between tool torque onset and peak flexor rms
EMG for the long torque build-up time (2 s) was 294 ms and decreased to 161 ms for the short buildup time (0.5 s). The findings suggested that torque reaction force can affect extrinsic hand muscles in the
forearm, and hence grip exertions, by way of a reflex response. Johnson and Childress (1988) showed
that low torque was associated with less muscular activity and reduced subjective evaluations of exertion.
Representative torque reaction force, handle kinematics, and EMG muscle activity are illustrated in
Figure 5.8. Since torque builds up in a clockwise direction, the reaction torque has a tendency to rotate the
tool counterclockwise with respect to the operator. When the operator has sufficient strength to react
against the reaction torque, the tool remains stationary or rotates clockwise and the operator exerts concentric
muscle contractions against the tool (positive work). However, when the tool overpowers the operator, it
tends to move in a counterclockwise direction and the operator exerts eccentric muscle contractions against
the tool (negative work). Therefore, measures of handle movement that occur (handle velocity and
displacement) and the direction of rotation can indicate relative tool controllability. Handle movement
direction was defined as positive when the handle moved in the direction of tool reaction torque (see
Figure 5.1). If handle velocity increases after shutoff, it means that the tool and hand are unstable. The
work done on the tool-hand system and the power involved in doing work during torque build-up were
also assessed. If the operator has the capacity to successfully react against the torque build-up (positive
work), then the tool is considered stable. This occurs when handle displacement and velocity were less
than zero. If the handle become unstable and the net handle displacement occurs in the direction of torque
reaction away from the operator, then work and power are negative.
A computer-controlled right angle nutrunner was used to study power hand tool reaction forces (Oh
and Radwin, 1997). A torque transducer and an angle encoder were integrated into the tool spindle
head which outputted analog torque and digital angular rotation signals. A threaded fastener joint
simulator that could be oriented horizontally or vertically was mounted on a height adjustable platform.
The longitudinal axis of the joint head was oriented perpendicular to the ground for the horizontal
work-station setting, and oriented parallel to the ground for the vertical workstation setting.

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Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 5.8 Representative torque reaction force, handle kinematics and EMG muscle activity for different torque
build-up times.

The study showed that workstation orientation and tool dynamics (torque reaction force and torque
build-up time) influenced operator muscular exertion and handle stability. In general, handle instability
increased when the tool was operated on a vertical workstation (rather than a horizontal workstation),
when torque reaction force was high (88.3 and 114.6 N), and for a 150 ms torque build-up time,
regardless of torque reaction force.
As torque reaction force increased from 52.1 N to 114.6 N, peak hand velocity 89%, and peak hand
displacement increased 113%. Peak hand velocity was greatest for a 150 ms build-up time and the least
for a 900 ms build-up time. The effect of target torque was consistent with previous studies that showed
that target torque was related to muscular exertion, subjective perceived exertion, and handle instability
(Johnson and Childress, 1988; Lindqvist, 1993; Oh and Radwin, 1994; Radwin et al., 1989). As torque
reaction force increased from 52.1 N to 114.6 N, the magnitude of negative work increased by 35%,
and the magnitude of average power against the operator increased by 30%. Under these conditions,
perceived exertion also increased from 2.7 to 4.3 (as rated on Borgs 10-point scale), and task acceptance
rate decreased from 73% to 28%. When the tool was operated on a horizontal workstation, average
finger flexor EMG was significantly influenced by torque reaction force. As torque reaction force increased
from 52.1 N to 114.6 N, the average flexor EMG increased by 14%.
The effect of torque build-up time on power hand tool operators has been studied in terms of perceived
exertion, muscular activity, and handle stability (Armstrong et al., 1994; Freivalds and Eklund, 1991;
Lindqvist et al., 1986; Oh and Radwin, 1994; Radwin et al., 1989). Torque build-up time is a concern
because it is directly related to assembly time and exertion duration. Increased duration may lead to
earlier fatigue onset. Although longer build-up time results in longer duration exertions and increases
the operation cycle time, it may provide an opportunity for better tool control since it gives the operator
a longer time to react.
Peak hand velocity was 5.7% less for horizontal workstations (mean = 0.46 m/s, SD = 0.26 m/s) than
for vertical workstations (mean = 0.67 m/s, SD = 0.34 m/s). A similar trend was observed for peak hand
displacement. Peak hand displacement for horizontal workstations (mean = 4.0 cm, SD = 2.2 cm) was
90.2% less than peak hand displacement for vertical workstations (mean = 7.6 cm, SD = 4.6 cm).
Previous findings agree that a horizontal workstation is preferable for right angle tool use. Ulin et al.
(1992) showed that average subjective ratings of perceived exertion were significantly less when the tool

Hand Tools: Design and Evaluation

5-11

was operated on horizontal workstations rather than vertical workstations. Also, 88% more negative
work and 58% more power against the operator were recorded while the tool was operated on a vertical
workstation. However, subjective ratings of perceived exertion and task acceptance rates did not differ
between horizontal and vertical workstations. This might come from the fact that the torque levels in
the current study were much greater than the torque level used for the Ulin et al. study (1992).
Although perceived exertion was less and task acceptance rate was greater for a 35 ms build-up time
than for longer build-up times, the operator might not have sufficient time to voluntarily react against
torque build-up with the 35 ms build-up time. On the average, the onset of the EMG burst occurred 40
ms after the onset of torque build-up for the 35 ms build-up time. This indicated that the muscles were
not activated until a significant amount of torque had built up for the 35 ms build-up time. Lack of
muscular contraction during torque build-up might explain why the peak handle velocity was higher for
short build-up times. Without muscular contractions, the inertia of the tool and hand had to absorb all
of the reaction force. Short exertion duration and lack of muscular contractions due to EMG latencies
might contribute to lower subjective ratings of perceived exertion for the 35 ms build-up.
The larger torque variance that occurred for the 35 ms build-up time indicated that even though
subjective perceived exertion was less, this condition might result in more target torque error. Also, the
probability of increased handle instability after shutoff was significantly greater for the 35 ms build-up
time. This suggests that even after shutoff, operators did not have sufficient capacity to control the tool
reaction torque. Therefore, the 35 ms build-up time increased handle stability in terms of peak handle
displacement and negative work, and reduced subjective perceived exertion, however, the lack of muscular
contraction during torque build-up reduced tightening quality.
Methods for limiting reaction force include (1) use of torque reaction bars, (2) installing torque absorbing
suspension balancers, (3) providing tool mounted nut holding devices, and (4) using tool support reaction
arms. A torque reaction bar sometimes can be used to transfer loads back to the work piece. Tools that can
be equipped with a stationary reaction bar adapted to a specific operation so reaction force can be absorbed
by a convenient solid object can completely eliminate reaction torque from the operators hand. These bars
can be installed on in-line and pistol-grip tools. Right angle tools can react against a solid object instead of
relying on the hand and arm. Reaction devices (1) remove reaction forces from the operator, (2) permit
pistol-grip and in-line reaction bar tools to be operated using two hands, (3) free the operator from restricting
postures, (4) provide weight improvements over right angle nutrunners, and (5) improve tool fastening
performance. The disadvantages are that reaction bars must be custom made for each operation, and the
combination of several attachments for one tool can be difficult. Torque reaction bars may also add weight
to the tool and can make the tool more cumbersome to handle.

5.6 Vibration
Vibration can be a by-product of power hand tool operation, or it can even be the desired action as is the
case with abrasive tools like sanders or grinders. Vibration levels depend on tool size, weight, method of
propulsion, and the tool drive mechanism. It is affected by work material properties, disk abrasives, and
abrasive surface area. Continuous vibration is inherent in reciprocating and rotary power tools. Impulsive
vibration is produced by tools operating by shock and impact action, such as impact wrenches or chippers.
The tool power source, such as air power, electricity, or hydraulics can also affect vibration. Vibration is
also generated at the tool-material interface by cutting, grinding, drilling, or other actions.
Pneumatic hammer recoil was observed producing a stretch reflex and muscular contractions in the
elbow and wrist flexors (Carls and Mayr, 1974). Studies of the short-term neuromuscular effects of
hand tool vibration have demonstrated that hand tool vibration can introduce disturbances in neuromuscular force control resulting in excessive grip exertions when holding a vibrating handle (Radwin et
al., 1987). The results of these studies demonstrated that grip exertions increased with tool vibration.
Average grip force increased for low frequencies (40 Hz) vibration but did not change for higher frequencies
(160 Hz) vibration. Since forceful exertions are a commonly cited factor for chronic upper extremity

5-12

Occupational Ergonomics: Engineering and Administrative Controls

muscle, tendon, and nerve disorders, vibrating hand tool operation may increase the risk of CTDs
through increased grip force.
Vibration has also been shown to produce temporary sensory impairments (Streeter, 1970; Radwin
et al., 1989). Recovery is exponential and can require more than 20 minutes (Kume et al., 1984).
Workers often sand or grind surfaces and periodically inspect their work using tactile inspection to
determine if the surface was sanded to the desired level of smoothness. Diminished tactility may result in
a surface feeling smoother than it actually is, resulting in a rougher surface than is actually desired.
Vibration has not been shown to be significantly reduced by using resilient mounts on handles.
Vibration isolation techniques have been generally unsuccessful for limiting vibration transmission from
power tools to the hands and arms. Isolation has been particularly difficult for vibration frequencies less
than 100 Hz. This is because attenuation only occurs when the vibration spectrum falls above the
resonant frequency of the isolation system or material. When the vibration frequency is less than the
resonant frequency of the isolating material, the handle acts as a rigid body and no vibration is attenuated.
Grinding tools typically run at speeds near 6000 rpm (100 Hz) making it difficult to have a resilient
vibration isolating handle. Furthermore, if the vibration frequency is approximately equivalent to the
isolator resonant frequency, the system will actually intensify vibration levels. Weaker suspension systems
have lower resonant frequencies, but are often impractical because such a system is usually too flexible
for the heavily loaded handles of tools like grinders. Handles loaded with high forces must be very rigid.

References
Armstrong, T.J., Bir, C., Finsen, L., Foulke, J., Martin, B., Sjgaard, G., and Tseng, K. 1994. Muscle
responses to torques of hand held power tools, Journal of Biomechanics, 26(6): 711718.
Ayoub, M.M. and Lo Presti, P. 1971. The determination of an optimum size cylindrical handle by use of
electromyography. Ergonomics, 14(4): 509518.
Fitzhugh, F.E. 1973. Dynamic Aspects of Grip Strength. (Tech Report). Department of Industrial &
Operations Engineering, Ann Arbor: The University of Michigan.
Freivalds, A. and Eklund, J. 1991. Subjective ratings of stress levels while using powered nutrunners, in
[Link] and [Link] (Eds.), Advances in Industrial Ergonomics and Safety III, New York:
Taylor & Francis, 379386.
Greenberg, L. and Chaffin, D.B. 1975. Workers and Their Tools: A Guide to the Ergonomic Design of
Hand Tools and Small Presses. Midland, MI: Pendell.
Hertzberg, H.T.E. 1955. Some contributions of applied physical anthropology to human engineering.
Annals of NY Academy of Science, 63(4): 616629.
International Organization for Standardization 1981. Hand-held Pneumatic Assembly Tools for Installing
Threaded FastenersReaction Torque Reaction Force and Torque Reaction Force Impulse
Measurements. ISO-6544.
Johnson, S.L. and Childress, L.J. 1988. Powered screwdriver design and use: tool, task, and operator
effects, International Journal of Industrial Ergonomics, 2:183191.
Kihlberg, S., Kjellberg, A., and Lindbeck, L. 1995. Discomfort from pneumatic tool torque reaction
force reaction: acceptability limits, International Journal of Industrial Ergonomics, 15:417426.
Lindqvist, B. 1993. Torque reaction force reaction in angled nutrunners, Applied Ergonomics, 24(3):
174180.
Lindquist, B., Ahlberg, E., and Skogsberg, L. 1986. Ergonomic Tools in Our Time. Atlas Copco Tools,
Stockholm.
Oh, S. and Radwin, R.G. 1993. Pistol grip power tool handle and trigger size effects on grip exertions
and operator preference, Human Factors, 35(3): 551569.
Oh, S. and Radwin, R.G., 1994, Dynamics of power hand tools on operator hand and arm stability, in
Proceedings of the Human Factors and Ergonomics Society 38th Annual Meeting, 602606, Santa
Monica, CA: Human Factors and Ergonomics Society.

Hand Tools: Design and Evaluation

5-13

Oh, S. and Radwin, R.G. 1998. The influence of target torque and torque build-up time on physical
stress in right angle nutrunner operation, Ergonomics, 41(2): 188206.
Petrofsky, J.S., Williams, C., Kamen, G., and Lind, A.R. 1980. The effect of handgrip span on isometric
exercise performance, Ergonomics, 23(12): 11291135.
Pronk, C.N.A. and Niesing, R. 1981. Measuring hand grip force using an application of strain gages,
Medical, Biological Engineering and Computing, 19:127128.
Putz-Anderson, V. 1988. Cumulative Trauma Disorders. New York: Taylor & Francis.
Radwin, R.G., Masters, G., and Lupton, F.W. 1991. A linear force summing hand dynamometer
independent of point of application, Applied Ergonomics, 22(5): 339345, 1991.
Radwin, R.G. and Haney, J.T. 1996. An Ergonomics Guide to Hand Tools, Fairfax, VA: American
Industrial Hygiene Association.
Radwin, R.G., VanBergeijk, E., and Armstrong, T.J. 1989. Muscle response to pneumatic hand tool
torque reaction force reaction forces, Ergonomics, 32(6): 655673.
Radwin, R.G., Oh, S., and Fronczak. 1995. A mechanical model of hand force in power hand tool
operation, Proceedings of the Human Factors and Ergonomics Society 39th Annual Meeting, Santa
Monica: Human Factors and Ergonomics Society: 348352.
Schmidt, R.T. and Toews, J.V. 1970. Grip strength as measured by the Jamar dynamometer, Archives of
Physical Medicine & Rehabilitation, 51(6): 321327.
Swanson, A.B., Matev, I.B., and Groot, G. 1970. The strength of the hand, Bulletin of Prosthetics
Research, Fall: 145153.
Ulin, S.S., Snook, S.H., Armstrong, T.J., and Herrin, G.D. 1992. Preferred tool shapes for various
horizontal and vertical work locations, Applied Occupational and Environmental Hygiene, 7(5):
327337.
Young, V.L., Pin, P., Kraemer, B.A., Gould, R.B., Nemergut, L., and Pellowski, M. 1989. Fluctuation in
grip and pinch strength among normal subjects, The Journal of Hand Surgery, 14A(1): 125129.

6
Gloves

Ram Bishu
University of Nebraska-Lincoln

[Link]
University of Nebraska-Lincoln

6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
6.11
6.12
6.13

Importance of the Hand

Prehensile Capabilities of Hand
eed for Protection of the Hand
Types of Gloves
Glove Effect on Strength
Glove Effect on Dexterity
Glove Effect on Tactility
Liners
Glove Attributes
Challenges of Glove Design
Glove Evaluation Protocol
Glove Standards
Conclusion

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6-1
6-2
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6-3
6-4
6-5
6-7
6-8
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6.1 Importance of the Hand

The hand is probably the most complex of all anatomical structures in the human body. Along with the
brain, it is the most important organ for accomplishing the tasks of exploration, prehension, perception,
and manipulation, unique to humans. The importance of the hand to human culture is emphasized by
its depiction in art and sculpture, its reference frequency in vocabulary and phraseology, and its importance
in communication and expression (Chao et al., 1989). The human hand is distinguished from that of the
primates by the presence of a strong opposable thumb, which enables humans to accomplish tasks
requiring precision and fine control. The hand provides humans with both mechanical and sensory
capabilities.

6.2 Prehensile Capabilities of the Hand

Napier (1956) divides hand movements into two main groupsprehensile movements, in which an
object is seized and held partly or wholly within the compass of the hand, and nonprehensile movements,
where no grasping and seizing is involved but by which objects can be manipulated by pushing or lifting
motions of the hand as a whole or of the digits individually.
Landsmeer (1962) further classifies human grasping capabilities as power grip, where a dynamic initial
phase can be distinguished from a static terminal phase, and precision handling, where there is no static
terminal phase. The dynamic phase as defined by Landsmeer includes the opening of the hand, positioning
of the fingers, and the grasping of the object. Westling and Johansson (1984) state that the factors that
influence force control during precision grip are friction, weight, and a safety margin factor related to the
individual subject. They also found that in multiple trials, the frictional conditions during a previous trial
could affect the grip force. They also showed that the grip employed when holding small objects stationary
in space was critically balanced such that neither accidental slipping between the skin and the object
0-8493-1800-9/03/$0.00+$1.50
2003 by CRC Press LLC

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Occupational Ergonomics: Engineering and Administrative Controls

TABLE 6.1 Comparison of Bare Hand-Gloved Hand
Capabilities

occurred, nor did the grip force reach exceedingly high values. This sense of critical balance as to the
amount of force applied while gripping is important, as too firm a grip could result in the destruction of a
fragile object, causing possible injury to the hand, or lead to muscle fatigue and interfere with further
manipulative activity imposed upon the hand. Sensory perception in the hand is due to the presence of
mechanoreceptors distributed all over the palmar area, especially at the tips of the fingers.
Thus, feedback from the hand is a critical component of the gripping task enabling the amount of
force to be controlled. Anything that blocks the transmission of impulses from the hand interferes with
the feedback cycle and affects grip force control. Gloves do affect the feedback cycle.

6.3 Need for Protection of the Hand

The hand, which provides humans with both mechanical and sensory capabilities, needs to be protected
from the environment. Protection is needed from mechanical trauma (abrasions, cuts, pinches, punctures,
crush injuries), thermal extremes (heat and cold), radiation (nuclear, ultraviolet, X-ray, and thermal),
chemical hazards, blood-borne pathogens, electrical energy, and vibration.
There exist several forms of hand protection, which can be used as stand-alone protection, or in
combination with other personal protective equipment. The commonly available hand protection are
gloves, mittens, finger cots, and gauntlets made of several materials such as leather, cotton, rubber,
nylon, latex, metal, and in combinations of the same, to provide maximum protection against the specific
condition being guarded against. The use of gloves, although a necessity in many workplaces, has some
associated disadvantages. Gloves have been found to affect hand performance adversely, and the
performance parameters affected are dexterity, task time, grip strength, and range of motion. Table 6.1
provides a summary of bare hand and gloved hand capabilities.
Facilitation of these activities, with simultaneous protection from the hazards of the work environment,
are often conflicting objectives of glove design. The conflicts associated with providing primary hand
protection through the use of a glove while permitting adequate hand functioning has been widely recognized.
It will be relevant to give a brief description of a variety of gloves that are available today. It will also
be relevant to discuss performance effects of gloves, before detailing the challenges of glove design.

6.4 Types of Gloves

There are a wide variety of gloves available today. Starting from a garden glove at 50 cents a pair from
the local grocery store to the custom-fit shuttle gloves donned by astronauts for extra vehicular activities

Gloves

6-3

(EVA), which cost a few hundred thousand dollars a pair, the variety among gloves can be so overwhelming
as to defy easy categorization. Gloves can be categorized along a number of dimensions, such as materials,
design, and location of use. According to the National Safety Council (1975, 1976), hand protection
can be job-rated or general purpose. Job-rated hand protection is designed to protect against the hazards
of specific operations, while general purpose gloves protect against many hazards. Materials used in
gloves are cotton, nylon, duck, jersey, canvas, terry, flannel, lisle, leather, rubber, synthetic rubber, wire
mesh, aluminized fabric, asbestos, plastic and synthetic coatings, impregnated fabrics, polyvinyl chloride,
nitrile, neoprene, and many man-made fibers with identifiable brand names (Dionne, 1979; Riley and
Cochran, 1988). Glove styles include liners, reversibles, open back, gloves or mittens with reinforced
nubby palms and fingers, and double-thumb gloves. Certain tasks may need double or more gloves. For
example, shuttle gloves are an assemblage of three layers of gloves, while latex-sensitive people in the
medical community wear an inner liner with an outer shell. The length of glove may be wrist-, elbow-,
or shoulder-length with exact dimensions depending on the manufacturer. In summary, the gloves range
from easily available general purpose ones to highly task-specific and job-rated ones.

6.5 Glove Effect on Strength

Grip strength: Published evidence exists for glove effect on grip strength, grasp strength, pinch strength,
grasp at submaximal levels of exertion, torque capabilities, and on endurance time. Reduction in grip and
grasp force when gloves are donned has been reported by a number of investigators (Hertzberg, 1955;
Lyman and Groth, 1958; Cochran et al. 1986; Wang et al. 1987; and Sudhakar et al. 1988). Hertzberg
(1955), using a Smedley hand dynamometer, determined that grip strength was reduced by about 20%
among gloved airplane pilots. Reduction in strength may be as much as 30% or more, according to Lyman
and Groth (1958). Cochran et al. (1986) performed an experiment which examined the differences in
grasp force degradation among five different types of commercially available gloves as compared to a barehanded condition. The results indicated that the no glove condition was significantly higher in grasp
force than any of the glove conditions. Wang et al. (1987) performed an experiment on strength decrements
with three different types of gloves. The results of the study showed that there was a reduction in grip
strength when comparing gloved performance to bare-handed performance. Bishu et al. (1995a, b) studied
the effects of EVA gloves at different pressures on human hand capabilities. A factorial experiment was
performed in which three types of EVA gloves were tested at five pressure differentials. The independent
variables tested in this experiment were gender, glove type, pressure differential, and glove make. Six
subjects participated in an experiment where a number of performance measures, namely grip strength,
pinch strength, time to tie a rope, and the time to assemble a nut and bolt, were recorded. Tactile sensitivity
was also measured through a two-point discrimination test. The salient results were that with EVA gloves
strength is reduced by nearly 50%, and that performance decrements increase with increasing pressure
differential. McMullin and Hallbeck (1991) studied the effect of wrist position, age, and glove type on the
maximal power grasp force, and their findings indicate that a single-layer glove is better than several
layers, as the bunching of glove material at the joints could cause strength decrement. More recently
Muralidhar et al. (1999) evaluated two prototype gloves (contour and laminated) with a single layer and
a double layered glove. Bare-hand performance was measured to assess the exact glove effect. Considerable
reduction in grip strength with gloves was found. Figure 6.1 shows the effect of gloves on grip strength.
Similar results were also reported by Bronkema and Bishu (1996).
In summary, most of the research evidence on gloves indicates that gloves reduce grip and grasp
capabilities.
Torque strength: A number of studies have reported an increase in strength capabilities with gloves.
Riley et al. (1985) examined forward handle pull, backward handle pull, maximum wrist flexion torque,
and maximum wrist extension torque while using no-glove, one-glove, and double-glove conditions.
The results of this study showed that the one-glove condition was superior to both the no-glove and
two-glove conditions. Similar results have been reported by Adams and Peterson (1988), who investigated
the effects of two types of gloves on torque capabilities. In this study, a two-layer work glove and a

6-4

Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 6.1 Gloves vs. grip strength.

threelayer chemical defense glove were found to enhance tightening performance, while only the work
glove aided the loosening performance. Mital et al. (1994) have reported an increase in peak torquing
exertion capabilities when gloves are donned, with the extent of increase being dependent on the type of
gloves donned. In contrast, Cochran et al. (1988) found that gloves reduce torquing force. They had
subjects perform a flexion torque task using four sizes of cylindrical handles (7 cm, 9 cm, 11 cm, and 13
cm) while wearing three types of gloves (cotton smooth leather, and suede leather). Using cotton gloves
yielded the lowest torquing force, while bare-handed had the highest, and the two leather gloves were in
between and were not significantly different from each other. These results are supported by Chen et al.
(1989), who found the forces generated using cotton gloves of all sizes were significantly lower than the
leather or deerskin gloves of different sizes in a similar torquing task. The effect of gloves on torque
capabilities is far less clear. However, it is reasonable to assume that gloves would aid torquing tasks.
Pinch strength: As compared to grip or grasp capabilities, studies on glove effect on pinch strength
are few and far between. Kamal et al. (1992) report that gloves do not affect lateral pinch capabilities.
Hallbeck and McMullin (1991, 1993) found similar results for three jaw chuck pinch. Overall, gloves
do not affect pinch strength.
Endurance time: Almost all activities with a gloved hand involve certain levels of hand exertions for
periods of time. Therefore, two issues are relevant here: the extent of exertion and the time of exertion.
Most of the published studies on gloves have addressed the issue of extent of exertion. Bishu et al. (1995b)
addressed the question of how long a person can sustain a level of exertion in the gloved-hand condition.
This deals with muscular fatigue and related issues. They reported that the endurance time at any exertion
level depended, not on the glove, but just on the level of exertion expressed as a percentage of maximum
exertion possible at that condition. There is, however, a glove effect for the maximum exertion. Figure 6.2
shows the plot of the exertion level effect on the endurance time, across all glove and pressure configurations.
The endurance time is least at 100% exertion level, while it is greatest at 25% exertion level.

6.6 Glove Effect on Dexterity

Bradley (1969) showed that control operation time was affected while wearing gloves. Banks and Goehring
(1979), while studying the effects of degraded visual and tactile information in diver performance, found
that the use of gloves increased task time by 50 to 60%. McGinnis et al. (1973) investigated the effect of
six different hand conditions on dexterity and torque capability. They used bare hand, leather glove,
leather glove with inserts, impermeable glove, impermeable glove with inserts, and an impermeable glove
with built-in insulation. They found that under dry conditions, the impermeable glove had the best torque
capability, and that the bare-handed dexterity performance was superior to that of gloved-hand performance.
Plummer et al. (1985) studied the effects of nine glove combinations (six double and three single) on

Gloves

6-5

FIGURE 6.2 Endurance time.

performance of the Bennett Hand Tool Dexterity Test apparatus. Results of the study indicated that
subjects, with gloves donned, took longer to complete the task, with the double glove causing longer
completion times. Cochran and Riley (1986) found that gloves generally reduce dexterity and force
capability. Bensel (1993) conducted an experiment in which the effects of three thicknesses (0.18 mm,
0.36 mm, and 0.64 mm) of chemical protective gloves on five dexterity tests (the Minnesota rate of
manipulation-turning; the OConnor finger dexterity test; a cord and cylinder manipulation; the Bennet
hand-tool dexterity test; and a rifle disassembly/assembly task) were investigated. Mean performance
times were shortest for the bare-handed condition and longest for the thickest (0.64 mm) glove. Nelson
and Mital (1995) found no appreciable differences in dexterity and tactility among latex gloves of five
different thicknesses: 0.2083 mm; 0.5131 mm; 0.6452 mm; 0.7569 mm; and 0.8280 mm. The authors
found the thickest latex glove (0.8280 mm) to be puncture resistant, with no loss in dexterity and
tactility as compared to the thinner gloves. Bellinger and Slocum (1993) investigated the effect of protective
gloves on hand movement and found that gloves decreased the range of motion in adduction/abduction
and supination/pronation, while extension/flexion was not affected. Their findings suggest that there is
an overall reduction in the kinematic abilities of the hand while wearing gloves. More recently Muralidhar
et al. (1999) evaluated two prototype gloves (contour and laminated) with a single layer, and a doublelayered glove. Bare-hand performance was measured to assess the exact glove effect. A battery of tests
consisted of the Pennsylvania Bi-Manual Worksample Assembly Test (PBWAT), Minnesota Rate of
Manipulation Test-Turning (MRMTT), a rope-tying task to evaluate dexterity for flexible object
manipulation, and a manipulability test. Figure 6.3 shows the glove effect on MRMTT. Figure 6.4
shows the plot of the glove effect on PBWAT. Figure 6.5 shows the glove effect on the rope tying time,
while Figure 6.6 shows the glove effect on the manipulation time. It is seen that gloves reduce dexterity.
The reduction in gloved performance is seen consistently in all the measures.
Overall, gloves reduce finger dexterity, and manipulability.

6.7 Glove Effect on Tactility

Although intuitively most obvious, the effect of gloves on tactile sensitivity has not been well documented.
The evidence on this matter is somewhat confusing mainly due to inadequacies of measures and inadequacies
of instruments. The monofilament test (Weinstein, 1993) is by far the most popular to assess tactile sensitivity.
Used in clinical testing, filaments with predetermined force are pressed against the fingers of the subjects by
the experimenter until the sensation of touch is felt. The force is recorded as the tactile sensitivity. The twopoint discrimination test used by OHara et al. (1988) and by Bishu and Klute (1995a) failed to give a clear
indication of loss of tactile sensitivity. Bronkema et al. (1994) have used grasp force degradation at
submaximal levels of exertion with gloves as a measure of the loss of tactility. Their results indicate that

6-6

Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 6.3 Gloves vs. pegboard time.

FIGURE 6.4 Gloves vs. number of assemblies.

FIGURE 6.5 Gloves vs. rope knotting time.

Gloves

6-7

FIGURE 6.6 Gloves vs. blocks manipulation time.

FIGURE 6.7 Glove effect on tactility.

gloves do reduce tactile sensitivity. Desai and Konz (1983) studied the effect of gloves on tactile inspection
performance and found that gloves had no significant effect on the inspection performance. In fact, they
recommend that gloves be worn during tactile inspection tasks to protect the inspectors hands from
abrasion and to help in the detection of small surface irregularities. Nelson and Mital (1995) found no
appreciable differences in dexterity and tactility among latex gloves of five different thicknesses. In
summary, the effect of gloves on tactility has not been clearly understood and should be the focus of
glove research in the future.

6.8 Liners
Today there is a growing trend toward the use of inner gloves or glove liners. For example, health care
professionals often tend to use glove liners to prevent outer glove/skin interaction. Similarly, meat
processors usually wear glove liners, while astronauts use multiple layers of liners. Almost all of the
research efforts on gloves has focused on the outer glove, while liners have drawn little research attention.
Using a standardized glove testing protocol, Bishu and Chin (1998) investigated the effect of a number
of glove liners.
The study compared three types of liners: liners made from PTFE, cotton, and latex. A battery of
evaluation tests, comprising some standardized tests and certain functional tests, was designed. The tests
assessed the following capabilities: tactile sensitivity, dexterity, manipulability, strength, and effect of
continuous use. The actual tests performed were the pinch test, finger strength test, monofilament test,

6-8

Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 6.8 Glove effect on overall fatigue.

pain threshold test, rope-tying test, peg board test, and fatigue test. In the fatigue test the effect of
continuous use of gloves was measured with Borgs RPE scale. Continuous use was simulated by making
the subjects perform keyboard tasks and peg board tasks alternately for an hour. Discomfort measures
were recorded every 10 minutes. Important findings were (a) liners made a distinct contribution to the
performance decrements with gloves, and (b) liners had a significant effect on the overall comfort
(discomfort) during extended periods of glove usage. Figure 6.7 shows the graph of effect of liners on
tactility as measured with monofilament test. Figure 6.8 shows the liner effect on overall fatigue.

6.9 Glove Attributes

Bradley (1969) also investigated dexterity as a function of glove attributes such as snugness of fit,
tenacity, and suppleness in a wide variety of 18 industrial gloves. The conclusions reached are that
various glove attributes influence dexterity performance to varying extents. Bishu et al. (1987) found
that glove attributes and the task performed had a significant effect on the force exertion. Wang et al.
(1987) concluded that altered feedback from a gloved hand caused strength degradation. Batra et al.
(1994) found grip strength reduction to be significantly correlated with glove thickness and subjective
rating discomfort, and suggest that glove thickness should be minimized, while increasing the tenacity.
In spite of these studies, no comprehensive model linking performance degradation with glove
characteristics exists.

6.10 Challenges of Glove Design

In summary, gloves do reduce performance, but provide a vital protective function. Facilitation of
performance, with simultaneous protection from the hazards of the work environment, are often
conflicting objectives of glove design. The conflicts associated with providing primary hand protection
through the use of a glove while permitting adequate hand functioning has been widely recognized.
Looking at the glove attributes that cause performance differences, attributes or level of attributes that
facilitate performance deteriorates safety function. This conflict poses certain challenges for the glove
designer. Before attempting to design any kind of protection for the hand, it is necessary to first identify
what it needs to be protected against. Human capability is limited to a narrow bandwidth of acceptable
environmental conditions in which performance is not affected. There are a number of environmental
hazards, often in combination, that are likely to pose a threat to the hands of workers interfacing with
their workplace.
Glove material is often fixed by the environment. Environments that expose the worker to radiation,
electrical, biological, fire, chemical, and extreme thermal hazards warrant that specific materials be
incorporated into the hand protection, irrespective of the design. The hazard-specificity of such materials

Gloves

6-9
TABLE 6.2 Glove Attributes as a Function of Design Parameters

also poses a problem for the glove designer, because the minimum thickness of the material required to
provide adequate protection is usually a fixed value, limiting the designers choice of variable parameters.
For example, a glove designed for use in an operating room or by a dental hygienist has to be capable
of being sterilized either by steam or chemical disinfectants, impermeable to any potentially dangerous
fluids, and of sufficient thickness and strength to maintain its integrity for a reasonable period of time.
However, in spite of the inflexibility in the materials parameters, the glove is expected to enable the
user to function without significant loss of desirable hand functions like grip strength, dexterity, range
of motion, and tactile feedback. When these requirements are combined with multiple hazard condition
protection requirements, glove design becomes a complex task. Table 6.2 shows the glove attributes as
a function of design parameters. Muralidhar et al. (1999) suggest an ergonomic approach for glove
design. Basing on published literature on force distribution in the hand during any task, they recommend
that gloves should have variable thickness, with more thickness in regions where more force is exerted
and less thickness in regions where force exertion is minimal. They argue that such an approach would
yield gloves with minimal performance degradation and maximal protection.

6.11 Glove Evaluation Protocol

The question of how to evaluate a glove has always interested the designer, manufacturer, and the user
of gloves. Standard evaluation protocols do not generally exist. Even in cases where they do exist, as in
cases of rubber gloves used by utility people or fire fighters gloves, the protocols are inadequate. It is
recommended that a typical glove evaluation protocol include the following:
1. Strength tests including grip and pinch tests.
2. A battery of standardized tests to assess dexterity, tactility, and manipulability. Typical standard
tests for these include Pennsylvania Bi-Manual Worksample Assembly Test (PBWAT), Minnesota
Rate of Manipulation Test-Turning (MRMTT), Purdue peg board test, OConnor dexterity test,
and Monofilament test.
3. A battery of functional tests. This is what most of the existing glove evaluation protocols lack.
Functional tests are task specific and should be appropriately designed to simulate actual tasks to
be performed with the concerned gloves.
Evaluation protocols similar to one listed above have been used by OHara et al. (1988) and Bishu and
Klute (1995a) in the evaluation of EVA gloves. Similar protocols have been used for evaluating liners by
Bishu and Chin (1998).

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Occupational Ergonomics: Engineering and Administrative Controls

6.12 Glove Standards

Existing glove standards are of three types. The standards generally describe protective requirements as
in some of the U.S. Occupational Safety and Health Administration standards; or describe the protection
the gloves must provide for safety as in gloves in the chemical industry or for the utility personnel; or
specifically describe glove testing requirements.

6.13 Conclusion
In summary, the following statements can be made with regards to gloves.
1. Gloves protect the hand from the environment, but affect the performance.
2. Gloves range widely in size, type, and cost. They range from general purpose gloves to highly
specialized task-specific gloves.
3. Gloves reduce grip or grasp strength capabilities, while they do not affect torque or pinch
capabilities.
4. Glove reduce hand dexterity, tactility, and manipulability.
5. Providing protection without compromising performance is a continuous challenge for glove
designers.

References
Adams, S.K. and Peterson, P.J. (1988). Maximum voluntary hand grip torque for circular electrical
connectors. Human Factors, 30 (6), pp. 733745.
Banks, W.W. and Goehring, G.S. (1979). The effects of degraded visual and tactile information on diver
work performance. Human Factors, 21 (4), pp. 409415.
Batra, S., Bronkema, L.A., Wang, M., and Bishu, R.R. (1994). Glove attributes: can they predict
performance? International Journal of Industrial Ergonomics, 14, pp. 201209.
Bellingar, T.A. and Slocum, A.C. (1993). Effect of protective gloves on hand movement: An exploratory
study. Applied Ergonomics, 24 (4), pp. 244250.
Bensel, C.K. (1993). The effects of various thicknesses of chemical protective gloves on manual dexterity.
Ergonomics, 36 (6), pp. 687696.
Bishu, R.R., Batra, S., Cochran, D.J., and Riley, M.W. (1987). Glove effect on strength: an investigation
of glove attributes. Proceedings of the 31st Annual Meeting of the Human Factors Society, pp. 901
905.
Bishu, R.R. and Chin, A. (1998). Inner gloves: How good are they? Advances in Occupational Ergonomics
and Safety 1998 (Editor [Link]) IDS Press, Ohio, 347400.
Bishu, R.R. and Klute, G. (1995a). The effects of extra vehicular activity gloves on human performance.
International Journal of Industrial Ergonomics, 16, pp. 165174.
Bishu, R.R., Klute, G., and Kim, B. (1995b). Force endurance relationship: does it matter if gloves are
donned? Applied Ergonomics, 26(3), pp. 179185.
Bradley, J.V. (1969). Effect of gloves on control operation time. Human Factors, 11(1), pp. 1320.
Bronkema, L. and Bishu R.R. (1996). The effects of glove frictional characteristics and load on grasp
force and grasp control. Proceedings of the 40th Annual Meeting of the Human Factors and Ergonomic
Society, Philadelphia, PA., pp. 702706.
Bronkema, L., Bishu, R.R., Garcia, D., Klute, G., and Rajulu, S. (1994). Tactility as a function of grasp
force: the effect of glove, pressure and load. Advances in Ergonomics and Safety VI (Editor:
Aghazadeh), Taylor & Francis Ltd., London, pp. 627632.
Chao, E.Y.S., An, K.N., Cooney, W.P., and Linschied, R.L. (1989). Biomechanics of the HandA Basic
Research Study, World Scientific, Singapore.

Gloves

6-11

Chen, Y., Cochran, D.J., Bishu, R.R., and Riley, M.W. (1989). Glove size and material effect on task
performance. Proceedings of the 33rd Annual Meeting of the Human Factors Society, Denver,
Colorado, pp. 708712.
Cochran, D.J. and Riley, M. (1986). The effects of handle shape and size on exerted forces. Human
Factors, 28 (3), pp. 253265.
Cochran, D.J., Albin, T.J., Bishu, R.R., and Riley, M.W. (1986). An analysis of grasp force degradation
with commercially available gloves. Proceedings of the 30th Annual Meeting of the Human Factors
Society, pp. 852855.
Cochran, D.J., Batra, S., Bishu, R.R., and Riley, M.W. (1988). The effects of gloves and handle size on
maximum torque. Proceedings of the 10th Congress of the International Ergonomics Association,
pp. 254256.
Desai, S. and Konz, S. (1983). Tactile inspection performance with and without gloves. Proceedings of
the Human Factors Society, pp. 782785.
Dionne, E.D. (1979). How to select proper hand protection. National Safety News, 119, pp. 4453.
Hallbeck, M.S. and McMullin, D.L. (1993). Maximal power grasp and three jaw chuck pinch as a
function of wrist position, age and glove type. International Journal of Industrial Ergonomics,
11(3), pp. 195206.
Hallbeck, M.S. and McMullin D.L. (1991). The effect of gloves, wrist position, and age on peak threejaw chuck pinch force: a pilot study. Proceedings of the Human Factors Society, 35th Annual Meeting,
pp. 753757.
Hertzberg, T. (1955). Some contributions of applied physical anthropometry to human engineering.
Annals of New York Academy of Sciences, 63, pp. 621623.
Kamal, A.H., Moore, B.J., and Hallbeck, M.S. (1992). The effects of wrist position/glove type on maximal
peak lateral pinch force. Advances in Industrial Ergonomics and Safety IV (Editor S. Kumar) London:
Taylor & Francis, pp. 701708.
Landsmeer, J.M.F. (1962). Power grip and precision handling. Annals of Rheumatic Disease, 21, pp.
164169.
Lyman, J. and Groth, H. (1958). Prehension force as measure of psychomotor skill for bare and gloved
hands. Journal of Applied Psychology, 42:1, pp. 1821.
McGinnis, J.S., Bensel, C.K., and Lockhar, J.M. (1973). Dexterity Afforded by CB Protective Gloves.
U.S. Army Natick Laboratories, Natick, Massachusetts, Report No. 7335-PR.
McMullin, D.L. and Hallbeck, M.S. (1991). Maximal power grasp force as a function of wrist position,
age, and glove type: A pilot study. Proceedings of Human Factors Society 35th Annual Meeting, pp.
733737.
Mital, A., Kuo, T., and Faard, H.F. (1994). A quantitative evaluation of gloves used with non-powered
hand tools in routine maintenance tasks. Ergonomics, 37, (2), pp. 333343.
Muralidhar, A. and Bishu, R.R., (1994) Glove evaluation: a lesson from impaired hand testing.
Advances in Industrial Ergonomics and Safety VI, Editor [Link]. Taylor & Francis. pp.
619625.
Muralidhar, A., Bishu, R.R., and Hallbeck, M.S. (1999). The development and evaluation of an ergonomic
glove. Applied Ergonomics, 30:6, pp. 555563.
National Safety Council, (1975). Programming personal protection: hands and fingers, National Safety
News, 114, pp. 5658.
National Safety Council, (1976). Keeping hands safe. National Safety News, 119, pp. 4453.
Napier, J.R. (1956). The prehensile movements of the human hand. The Journal of Bone and Joint
Surgery, 38B, pp. 902913.
Nelson, J.B. and Mital, A., (1995). An ergonomic evaluation of dexterity and tactility with increase in
examination/surgical glove thickness. Ergonomics, 38(4), pp. 723733.
OHara, J.M., Briganti, M., Cleland, J., and Winfield, D. (1988). Extravehicular activities limitations
study. Volume II: establishment of physiological and performance criteria for EVA glovesfinal
report (Report number AS-EVALS-FR-8701, NASA Contract no NAS-9-17702).

6-12

Occupational Ergonomics: Engineering and Administrative Controls

Plummer, R., Stobbe, T., Ronk, R., Myers, W., Kim, H., and Jaraiedi, M. (1985). Manual dexterity
evaluation of gloves used in handling hazardous materials. Proceedings of the 29th Annual Meeting
of the Human Factors Society, pp. 819823.
Riley, M.W. and Cochran, D.J. (1988). Ergonomic aspects of gloves: design and use. International
Reviews of Ergonomics, 2, Editor David [Link], Taylor & Francis, pp. 233250.
Riley, M.W., Cochran, D.J., and Schanbacher, C.A. (1985). Force capability differences due to gloves.
Ergonomics, 28 (2) pp. 441447.
Sudhakar, L.R., Schoenmarklin, R.W., Lavender, S.A., and Marras, W.S. (1988). The effects of gloves on
muscle activity. Proceedings of the 32nd Annual Meeting of the Human Factors Society, pp. 647
650.
Wang, M.J., Bishu, R.R., and Rodgers, S.H. (1987). Grip strength changes when wearing three types of
gloves. Proceedings of the Fifth Symposium on Human Factors and Industrial Design in Consumer
Products, Interface 87, Rochester, NY.
Weinstein, S. (1993). Fifty years of somatosensory research: from the Semmes-Weinstein monofilaments
to the enhanced sensory test. Journal of Hand Therapy, January-March, pp. 1122.
Westling, G. and Johansson, R.S. (1984). Factors influencing the force control during precision grip.
Experimental Brain Research, 53, pp. 277284.

7
Industrial Mats
7.1
7.2
7.3
7.4
7.5
7.6
7.7

Introduction
Psychophysical Approach
Physiological Approach
Postural Approach
Biomechanical Approach
Characteristics of Tested Mats
A Standardized Protocol

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7-1
7-2
7-2
7-3
7-3
7-3

Jung-Yong Kim

7.8

Standardized Compressibility Measure

Foot Wear Conditions

7-5

Hanyang University

7.9 Suggestions for the Ergonomist

7-5

7.1 Introduction
Prolonged standing on ones feet is very common in the workplace. Workers who are exposed to prolonged
standing often experience fatigue, discomfort, and swelling of the legs and feet (Winkel, 1981; Rys and
Konz, 1989). Ryan (1989) showed that supermarket cashiers, who stood 90% of their working hours,
experienced discomfort mostly in the lower back area. Redfern and Chaffin (1988) reported a significant
level of fatigue and discomfort in various areas of the body after prolonged standing.
Many studies have shown that the lack of venous return in the lower extremities increased discomfort
during prolonged standing (Brantingham et al., 1970; Winkel and Jorgensen, 1986; Konz et al., 1990).
Local muscle fatigue in the lower back area has also been observed after two hours of standing (Kim et
al., 1994). Likewise, the cause of discomfort and fatigue can be different depending upon the related
body parts.
In industry, floor mats have been widely distributed as a quick remedy to help reduce the discomfort
and fatigue of workers. However, there is no documented guideline to choose the proper matting for an
individuals working condition. This made it difficult for ergonomists or safety managers to objectively
evaluate mats for their own workplaces. Therefore, in this chapter, various studies are introduced and
compared to help readers understand different approaches and testing methods. Furthermore, a few tips
or guidelines in the selection of a proper mat are summarized based upon the results of these studies.

7.2 Psychophysical Approach

A subjective rating technique for postural discomfort (Corlett and Bishop, 1976) has been employed to
examine the level of discomfort in various body parts after prolonged standing. In this technique, workers
can score the level of discomfort by using a body diagram, even though it only provides subjective opinions.
Redfern and Chaffin (1988) used this technique to examine the overall body fatigue and leg fatigue in nine
different floor conditions at the end of the workday. They asked about the discomfort level of the feet,
ankle, shank, knee, thigh, hips, lower back, and upper back. They found that all thebody parts except for
0-8493-1800-9/03/$0.00+$1.50
2003 by CRC Press LLC

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7-2

Occupational Ergonomics: Engineering and Administrative Controls

the legs and hips indicated significant differences in a discomfort rating with achange in the floor conditions.
In their study, the feet showed the highest discomfort rating followed bythe ankle and shank. Regarding
the floor conditions, the relatively soft mats consistently showed lessdiscomfort than the concrete floor or
the hard mat. However, the uneven soft surface showed a relativelyhigher rating of tiredness despite its
softness. No quantitative data were reported to specify the propercompressibility of mats in this study. It
was concluded that the different hardness and depth, as well asthe viscoelastic property of the mat are the
main factors in determining the effectiveness of the mat.
Konz et al. (1990) investigated three different mats and a concrete surface. Twenty college students stood
on mats for 90 minutes, and discomfort levels were examined from the neck, shoulder, upper back, mid
back, lower back, buttocks, upper leg, lower leg, ankle, hind foot, mid foot, and fore foot. As a result, all
of the lower parts of the body from the buttocks down were significantly affected by the floor surfaces. All
three mats in this study showed a significant reduction of discomfort compared to the concrete surface.
Importantly, the compressibility of the mats was quantitatively reported based upon the technique developed
by Konz and Subramanian (1989). In this study, the comfort level was inversely related to the mat
compressibility. In other words, the harder the mat was, the more effective it was in reducing discomfort,
which was the reverse outcome compared to the previous study by Redfern and Chaffin (1988).
Hinnen and Konz (1994) tested five different mats by using a compressibility measure (Konz and
Subramanian, 1989). They tested 16 female subjects standing an entire shift for 2 days. Each hour they
measured the discomfort levels of nine body regions. After they compared five mats in terms of discomfort
level and compressibility, they found that there was an optimal range of thickness and compressibility of
the mats to maximize the reduction of discomfort. They concluded that the most comfort can be provided
when the mat is at least 1/2 inch thick and 3 to 4% compressible.
From the results of these studies, it was found that the discomfort level increased with time and
appeared to be the greatest at the feet, and became progressively less and less from the feet up. Also, the
surface type, thickness, and compressibility of the mat have been recognized as important factors in
determining the anti-fatiguing effect during prolonged standing.

7.3 Physiological Approach

During a period of prolonged standing or sitting, the hampered venous and arterial circulation of the
lower leg (Basmajian, 1979; Brantingham, 1970; Winkel and Jorgensen, 1986) can cause foot swelling
or skin temperature change, which are signs of discomfort and tiredness of the leg.
Changes in foot dimension and skin temperature were measured by Rys and Konz (1989) and Konz
et al. (1990). They examined the changes in foot length, width, thickness, and ankle thickness after
standing for 90 minutes and found no significant differences with a variety of floor surfaces. The calf
circumference was also measured by Kuorinka et al. (1978) after one hour of standing. The result
showed 3.5 to 1 mm increase in calf circumference in an hour, but the increase somewhat leveled off
toward the end of the session for half of the participants. Eventually, no difference in calf circumference
was found on the three surfaces.
Skin temperature was measured from the calf and instep by Konz et al. (1990). They observed that the
calf skin temperature had increased by 0.3 C for the concrete surface, while small or negative increases
were recorded for the mat. Conversely, Rys and Konz (1989) reported that the calf skin temperature
measured on the concrete was significantly lower, by 1.5 and 1.9 C, compared to the rubber mat after an
hour of standing. No skin temperature change was found in the instep as the floor surface varied.

7.4 Postural Approach

The frequency of posture shifting was observed by a video recorder, and the center of gravity of body
sway was measured by force platform by (Zhang et al., 1991). They found that the frequency of posture
shift is a sensitive measure to show the effect of prolonged hours of standing, but it is a poor indicator

Industrial Mats

7-3

of showing the difference in floor types. Kuorinka et al. (1978) also measured the frequency of a postural
sway at the beginning and the end of one hour of standing. An increase of frequency was found at the
end of the session, but no difference was found between the three different surfaces.

7.5 Biomechanical Approach

An electromyographic (EMG) study (Basmajian 1979) showed that the standing posture can be maintained
by muscle activities in the solius, iliopsoas, sacrospinalis, and neck extensor. Kuorinka et al. (1978)
examined the EMG signals of the solius muscle and showed a slight trend for the integrated EMG
(IEMG) to rise on a concrete surface, although the initial IEMG was the lowest. Zhang et al. (1991)
measured EMG from the tibialis anterior and gastrocnemius muscles during and after two hours of
standing and found no differences in the fatigue level as the thickness of the floor changed.
Marras (1992) pointed out that the processed EMG used in previous studies simply indicated the
level of muscle contraction that could be a very weak indicator of muscle fatigue during static standing.
He suggested that the EMG power spectrum could be a more effective tool for detecting the localized
muscle fatigue after prolonged standing than the processed EMG. LeVeau and Andersson (1992) used a
spectral analysis to derive EMG power frequency distribution that is the second-order information of an
IEMG signal. They showed that the shift of mean or median value of a frequency distribution could be
used as a sign of local muscle fatigue.
Kim et al. (1994) studied muscle fatigue after a period of two hours of standing by using the EMG
power spectrum. The erector spinae muscle as well as tibialis anterior and gastrocnemius muscle were
examined. Three floor conditions including concrete, thin mat, and thick mat were tested. The
compressibility of the mat was also quantified based on the method used by Konz and Subramanian
(1989). The Kin/Com dynamometer was used to measure the 75% of maximum voluntary contraction
(MVC) before and after prolonged standing. The IEMG immediately recorded after two hours of standing
and the median frequency shift of the EMG power spectrum was computed. In the study, a more local
muscle fatigue in the erector spinae muscle rather than the lower leg muscles was found. The significant
increase of the processed IEMG signal was also observed in the leg muscles, however, that was not
necessarily the sign of local muscle fatigue. It was stated that the decreased discomfort on the softer mat
could be due to the active venous return following lower leg contraction on a soft surface.

7.6 Characteristics of Tested Mats

Various types of mats have been tested in different studies. Currently, individual mats cannot be
quantitatively compared to each other because test protocols are not yet standardized for the studies. In
spite of this, test results in different studies are summarized in Table 7.1. The comfort score in this table
should not be used for direct comparison between mats.

7.7 A Standardized Protocol

A standardized protocol needs to be developed to quantitatively evaluate mats. The protocol is expected to
specify the method and apparatus to measure the thickness and compressibility of material. The material
can be further specified in terms of resiliency and elasticity if an apparatus such as an Instron machine is
available. Moreover, surface type can be specified in terms of the shape and friction coefficient. In general,
the standing period needs to be longer than an hour to see signs of discomfort. Since the standing posture
may change the result greatly, the posture needs to be standardized and strictly instructed during the test.

Standardized Compressibility Measure

Konz and Subramanian (1989) computed an average foot pressure based upon the average male body
weight of 170 lb. (77.3 kg), which is 0.35 kg/cm2. If one uses a 7 7 cm mat specimen, 17.15 kg of force

n/a: not available.

1
The absolute amount of compressed part under the given pressure (Equation 1)
2
The amount of compressed part relative to the original depth of mat

TABLE 7.1 Characteristics of Various Mats

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Occupational Ergonomics: Engineering and Administrative Controls

Industrial Mats

7-5

should be applied to generate the same average foot pressure on the specimen. In actual testing, 18 kg
instead of 17.15 kg was used to record the compressibility of the mat. The duration of compression
should be short enough (about a second) to simulate the actual foot-stepping situation. The equation
computing the average adult foot pressure (Konz and Subramanian, 1989) is as follows:
(7.1)
A proper press machine should be used to control the pressure level precisely. The following are examples
of devices used in previous studies:
1. Instron machine (Redfern and Chaffin, 1988), Instron model 1122 universal testing machine
(Konz et al., 1990).
2. MTS Bionix 858 servo hydraulic materials testing system (Kim et al., 1994)

7.8 Foot Wear Conditions

The discomfort level can be greatly affected by footwear as well as the characteristics of the mat itself.
That is, the standardized test also needs to be specified in terms of footwear conditions, and the results
should be interpreted accordingly. The following are examples of the various footwear used in previous
studies.
1.
2.
3.
4.
5.

Working shoes (Redfern and Chaffin, 1988)

Thin-soled sneakers (Kuorinka et al., 1978)
Dress shoes with hard insole and sneaker with soft insole (Zhang et al., 1991)
Cotton socks and slippers (Konz et al., 1990)
Cotton socks without shoes (Kim et al., 1994)

Moreover, the final selection of mats should be made after considering the interactive effect between
shoes and mats. The right combination of the two materials not only increases the comfort level but can
also prevent slips and falls in the workplace. To quantitatively assess the interaction between shoes and
mats, Redfern and Bidanda (1994) measured the friction level in terms of proper parameters including
dynamic coefficient of friction. Leclercq et al. (1995) also suggested the use of reference conditions
including lubricant, floor surface and footwear model to accurately measure the slipping resistance.

7.9 Suggestions for the Ergonomist

Selecting the best mat is not a simple task. Commercialized mats sometimes use materials with different
compressibility for each foot. This type of mat may be able to stimulate the venous circulation of one leg
better than the other. However, it has not been adequately studied to determine how effective those specially
designed mats are. Presently, the simple and safe way of selecting a mat is to choose one that is not too
hard, not too soft. For example, workers who stand and walk around may need a good hard and even
surface to minimize unnecessary ankle action to balance their posture. At the same time, the softness of the
mat helps the blood pumping mechanism while standing quietly to reduce the discomfort level. Therefore,
the combination of solid surface and a soft padding may meet the needs of workers who both walk and
stand. In summary, the surface shape, softness, thickness, kind of padding, and material should be carefully
considered in selecting the right mat to meet the specific requirements of an individuals workplace.
Further research should be conducted under the standardized protocol to acquire information on the
anti-fatiguing and anti-slipping effect of various mats. Then, a quantitative ergonomic guideline can be
developed based upon the standardized data. Eventually, such guidelines will help ergonomists and
safety managers select the best mat for the individual worker.

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References
Basmajian, J.V. and DeLuca, C. 1979. Their functions revealed by electromyography, in Muscle Alive.
Williams & Wilkins, Baltimore, MD.
Brantingham, C.R., Beekman, B.E., Moss, C.N., and Gorden, R.B. 1970. Enhanced venous blood pump
activity as a result of standing on a varied terrain floor surface. Journal of Occupational Medicine,
12:164169.
Corlett, E.N. and Bishop, R.P. 1976. A technique for assessing postural discomfort. Ergonomics, 19(2):
175182.
Hinnen, P. and Konz, S. 1994. Fatigue mats. Advances in Industrial Ergonomics and Safety VI, Taylor
& Francis. 323327.
Kim, J.Y., Stuart-Buttle, C., and Marras, W.S. 1994. The effects of mats on back and leg fatigue. Applied
Ergonomics, 25(1): 2934.
Konz, S., Bandla, V., Rys, M., and Sambasivan, J. 1990. Standing on concrete vs. floor mats. Advances
in Industrial Ergonomics and Safety II, Taylor & Francis. 991998.
Konz, S. and Subramanian, V. 1989. Footprints. Advances in Industrial Ergonomics and Safety I, Taylor
& Francis. 203205.
Kuorinka, I., Hakkanen, S., Nieminen, K., and Saari, J. 1978. Comparison of floor surfaces for standing
work. Biomechanics VI-B, 207211.
Leclercq, S., Tisserand, M., and Saulnier, H. 1995. Assessment of slipping resistance of footwear and
floor surfaces. influence of manufacture and utilization of the products. Ergonomics, 38(2): 209
219.
LeVeau B. and Andersson, G. 1992. Output forms: data analysis and applications. Interpretation of
electromyographic signals. Selected Topics in Surface Electromyography for Use in the Occupational
Setting: Expert Perspectives. U.S. Department of Health and Human Services. 70102.
Marras, W.S. 1992. Applications of electromyography in ergonomics. Selected Topics in Surface
Electromyography for Use in the Occupational Setting: Expert Perspectives. U.S. Department of
Health and Human Services. 122143.
Redfern, M.S. and Bidanda, B. 1994. Slip resistance of the shoe-floor interface under biomechanicallyrelevant conditions. Ergonomics, 37(3): 511524.
Redfern, M.S. and Chaffin, D.B. 1988. The effect of floor types on standing tolerance in industry.
Trends in Ergonomics/Human Factors V, (Ed.) F. Aghazadeh, Elsevier Science Pub.
Ryan, G.A. 1989. The prevalence of musculoskeletal symptoms in supermarket workers. Ergonomics,
32: 359371.
Rys, M.J. and Konz, S. 1989. Standing with one foot forward. Advances in Industrial Ergonomics and
Safety I, (Ed.) A. Mital, Taylor & Francis.
Rys, M.J. and Konz, S. 1989. An evaluation of floor surfaces. Proceedings of the Human Factors Society
33rd Annual Meeting. 517520.
Rys, M. and Konz, S. 1990. Floor surfaces. Proceedings of the Human Factors Society 34th Annual
Meeting. 575579.
Winkel, J. 1981. Swelling of the lower leg in sedentary workpilot study. Journal of Human Ergology,
10:139149.
Winkel, J. and Jorgensen, K. 1986. Evaluation of foot swelling and lower-limb temperature in relation
to leg activity during long-term seated office work. Ergonomics, 29(2): 313328.
Zhang, L. Drury, C.G., and Woollet, S.M. 1991. Constrained standing: evaluation of the foot/floor
interface. Ergonomics, 34:175192.

8
Ergonomic Principles
Applied to the
Prevention of Injuries to
the Lower Extremity
Steven [Link]
Rush-Presbyterian-St. Lukes
Medical Center

Gunnar [Link]
Rush-Presbyterian-St. Lukes
Medical Centers

8.1 Lower Extremity Injuries: Is There an

Occupational Problem?
8.2 Preventing Injury: Types of Ergonomic Controls

81
84

Floor Mats Shoe Insoles The Foot-Floor

Interface Stair Design Help for Those in

Kneeling Postures
8.3 Summary

88

Most of the ergonomics literature dealing with the prevention and control of musculoskeletal disorders
in the workplace has focused on the upper extremity and the back. Comparatively little attention has
been given to lower extremity musculoskeletal disorders which occur in the workplace. One could argue
that since the lower extremity problems are not well documented in ergonomic journals, the problems
may not be of much practical significance. The first objective of this chapter is to review the current
literature regarding occupational musculoskeletal disorders affecting the lower extremities and to
demonstrate the significance of the problem. The second objective is to describe what types of intervention
strategies are available to minimize the likelihood of future or recurrent injuries to the feet, ankles,
knees, and hips.

8.1 Lower Extremity Injuries: Is There an Occupational Problem?

The sports medicine literature is full of lower extremity overuse injuries in athletes. All too often we
have seen athletes relegated to the sidelines following some sort of soft tissue injury that is likely to be
the effect of not just a single incidence, but rather a cumulative loading pattern during practice and
competition. Luckily, in most occupational environments the intensity of the exercise is greatly diminished,
however, the cumulative exposure problem still persists. Recent studies have begun to report the
relationship between occupational factors and knee, hip, and foot trauma.
Lindberg and Axmacher (1988) reported the prevalence of coxarthosis in the hip to be greater in
male farmers than in an age-matched group of urban dwellers. Vingard et al. (1991) classified bluecollar occupations as to whether static or dynamic forces could be expected to act on the lower extremity.
The authors found that those employed in occupations that experienced greater loads on the lower
extremity, namely farmers, construction workers, firefighters, grain mill workers, butchers, and meat

0-8493-1800-9/03/$0.00+$1.50
2003 by CRC Press LLC

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Occupational Ergonomics: Engineering and Administrative Controls

preparation workers, had an increased risk of osteoarthrosis of the hip. Similarly, Vingard et al. (1992)
found that disability pensions for hip osteoarthrosis were significantly more likely to be received by
males employed as farmers, forest workers, and construction workers.
Lindberg and Montgomery (1987) reported that knee gonarthrosis (osteoarthritis), as defined by a
narrowing of the joint space with a loss of distance between the tibia and the femur in one compartment,
of one-half or more of the distance in the other compartment of the same knee joint or the same
compartment of the other knee, or less than 3 mm, was more common in those who had performed
jobs that required heavy physical labor for a long time. Kohatsu and Schurman (1990) found that,
relative to controls, the individuals with severe OA were two to three times more likely to have worked
in occupations requiring moderate to heavy physical work. Anderson and Felson (1988) reported a
relationship between the frequency of knee bending required in a respondents occupation and
osteoarthritis in the older working population (55 to 64 years). Moreover, these same authors have
shown that the strength demands of the job were predictive of knee OA in the women from this older
age group (Anderson and Felson, 1988). The authors suggest that the increased OA in those with long
exposure to occupational tasks is indicative of the role of repetitive occupational exposure. Further
supporting the link between material handling jobs and knee problems is the finding by McGlothlin
(1996), who recently reported that beverage delivery personnel were experiencing discomfort in the
knees, in addition to the anticipated discomfort in the back and shoulders. It should be recognized,
though, that personal risk factors for osteoarthrosis of the knee include obesity and significant knee
injury (Kohatsu and Schurman, 1990). These same authors found no relationship between leisure time
activities and knee OA.
Torner et al. (1990) reported that chronic prepatellar bursitis was the predominant knee disorder in
120 fishermen who underwent an orthopedic physical examination. Forty-eight percent of the men
examined showed this disorder. Interestingly, the finding was as common among younger men as in
older men. The authors believe that this disorder is a secondary effect of the boats motion. The knees
are used to stabilize the body by pressing against gunwales or machinery as tasks are performed with the
upper extremities. Furthermore, just standing in mild sea conditions (maximum roll angles of 8 degrees)
has been shown to considerably elevate the moments at the knees as the motion in the lower extremities
and the trunk are the primary means for counteracting a ships motions (Torner et al., 1991).
The etiology of beat knee was described by Sharrard (1963). He reported on the examination of
579 coal miners. Forty percent of those examined were symptomatic or had previously experienced
symptoms. Most of the injuries could be characterized as acute simple bursitis or chronic simple bursitis.
The majority of the affected miners were colliers whose job requires constant kneeling at the mine face.
There was a strong relationship between the coal seam height (directly related to roof height in a mine)
and the incidence of beat knee. The incidence rates were much higher in mines with a roof height under
four feet as compared with those with greater roof heights. Obviously, this factor greatly affects the
work posture of the miners. With higher roof heights miners can alternate between stooped and kneeling
postures, but when seams are one meter or less, the stooped posture is no longer an alternative. Gallagher
and Unger (1990), for example, present recommendations for weight limits of handled materials in
underground mines. Below 1.02 m these are based on miners in kneeling postures. Sharrard (1963) also
speculated on the individual factors attributable to the disorder and found a higher incidence among
younger men. However, this may be due to the healthy worker effect (Andersson, 1991) in which
older miners with severe beat knee have left the mining occupation.
Tanaka et al. (1982) reported that the occupational morbidity ratios for workers compensation
claims of knee-joint inflammation among carpet installers was twice that found in tile setters and floor
layers, and was over 13 times greater than that of carpenters, sheet metal workers, and tinsmiths. Others
have shown the knees of those involved with carpet and flooring installation were more likely to have
fluid collections in the superficial infrapatellar bursa, have a subcutaneous thickening in the anterior
wall of the superficial infrapatellar bursa, and have an increased thickness in the subcutaneous prepatellar
region (Myllymaki et al., 1993).

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Thun et al. (1987) determined the incidence of repetitive knee trauma in the flooring installation
professions. While all flooring installers spend a large amount of time kneeling, the authors divided the
154 survey respondents into two groups, tilesetters and floor layers, based on their use of a kneekicker. This device is used to stretch the carpet during the installation process. These respondents were
compared with a group of millwrights and brick layers whose jobs did not require extended kneeling
and/or the use of a knee kicker. Of the 112 floor layers (those who used the knee kicker) the prevalence
rate of bursitis was approximately twice that found in the 42 tilesetters, and over three times that found
in the 243 millwrights and brick layers. However, the prevalence in both groups of flooring workers of
having required needle aspiration of the knee was almost five times that of millwrights and bricklayers.
These results suggest that long durations of occupational kneeling is related to fluid accumulation, yet
the bursitis is due to the repetitive trauma endured by the floor layers using the knee kicker. Village et al.
(1991) found that the peak impulse forces generated in the knees of carpet-layers when using the kneekicker were on the order of 3000 N. The opposite knee which was supporting the body during this
action had an average peak force of 893 N. Bhattacharya et al. (1985) reported knee impact forces of
2469 N (about three times body weight) for a light kick and 3019 N (or about four times body weight)
for a hard kick. These light and hard kicks resulted in impact decelerations of 12.3 g and 20 g, respectively.
The authors observed that the knee kicking action during flooring installation occurred at a rate of 141
kicks per hour. Putting the knee injuries in perspective, pain was reported by 22% of questionnaire
respondents in the tufting job at a carpet manufacturer. However, knees were only listed in 2.4% of the
accident records. Thus, the knee is frequently the site of discomfort, although there may be few lost days
associated with knee pain (Tellier and Montreuil, 1991).
Cumulative trauma injuries can take the form of stress or fatigue fractures. Linenger and Shwayhat
(1992) reported training-related injuries to the foot occurred in military personnel undergoing basic
training at a rate of three new injuries per 1,000 recruit days. These authors found that stress fractures
to the foot, ankle sprains, and achilles tendinitis accounted for the bulk of the injuries. Anderson (1990)
found the stress fractures to be most common in the distal second and third metatarsal bones but could
occur in any of the bones in the foot. Giladi et al.s (1985) findings indicated that 71% of the stress
fractures in their sample of military recruits occurred in the tibia and 25% in the femoral shaft. Moreover,
they found the fractures to occur later in the training process than reported by others. Jordaan and
Schwellnus (1994) reported that overuse injuries, when normalized according to training hours per
week, decreased from week 1 to week 4, showed a resurgence in week 5, and a large peak in the final
week of training. The injury rates corresponded to the weeks in which there was increased marching and
less field training.
With regard to the overuse injuries found in military recruits, some investigators have looked into
aspects of lower limb morphology that may indicate which individuals will be more susceptible to injury
while performing the tasks associated with military training. Giladi et al. (1991) reported the influence
of individual factors on the incidence of fatigue fractures, specifically, they found that individuals with
narrow tibiae, and/or a greater external rotation of the hip were more likely to experience fatigue fractures.
Cowan and colleagues (1996) reported the relative risk of overuse injuries was significantly higher in
military recruits with the most valgus knees. In addition, these authors showed that the Q angle,
which defines the degree of deviation in the patellar tendon from the line of pull on the patella by the
quadriceps muscles, was shown to be predictive of stress fractures.
In summary, several occupational risk factors have been identified which place an employee at increased
risk for disorders in the lower extremity. The literature has shown that heavy physical labor and frequent
knee bending are factors, especially in the older component of the work force, thereby suggesting an
interaction between the age degenerative processes and cumulative work experience. In other occupations
the risk of lower extremity disorders is increased through poor footing conditions. And clearly, the role
of direct cumulative trauma in those employees who must maintain kneeling postures and use their
knees to strike objects (knee kicker) cannot be overlooked when considering preventive measures.

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Occupational Ergonomics: Engineering and Administrative Controls

8.2 Preventing Injury: Types of Ergonomic Controls

Several types of control mechanisms to prevent or accommodate lower extremity disorders are available.
This section will focus on the techniques whereby the foot-floor interface can be optimized. This includes
measures to prevent slips and falls, stress fractures, as well as improving circulation and comfort in the
lower extremities for those who remain in relatively static work postures throughout the day.

Floor Mats
Floor mats are often used for local slip protection. While inexpensive, they create a possible trip hazard,
interfere with operations or cleanliness, and wear excessively (Andres et al., 1992). Several investigators
have looked into the use of floor mats to reduce the fatigue effects observed in jobs that require prolonged
standing. The subjects tested by Kuorinka et al. (1978) indicated through subjective ratings that they
preferred to work on softer surfaces as opposed to harder surfaces. A foam plastic surface was rated the
best and concrete the worst. These authors reported a moderate correlation between the subjective
comfort ratings of the five surfaces tested and the order of surface hardness. However, integrated
electromyographic (EMG) signals, median frequency of the EMG, measures of postural sway, and measures
of calf circumference did not show any significant difference due to the floor covering. Hinnen and
Konz (1994) asked employees in a distribution center to stand for two 8-hour shifts on each of five mats
tested in the study. Approximately every hour the employees rated their comfort in several body regions
including the upper leg, lower leg, ankle, and back. A scale of 0 (no discomfort at all) to 10 (extreme
discomfort) was used. While these workers experienced relatively little discomfort, the mats with
compressibility between 3 and 4% did best in the upper leg discomfort rankings as well as subject
preference rankings. Marginally significant changes in the discomfort ratings were reported for the
ankle. The ratings of lower leg and back discomfort showed no significant differences.
Rys and Konz (1989,1990) reported on several anthropometric and physiological measures including
changes in foot size and skin temperature at the instep and the calf. In general, the mats included in this
study were significantly different from concrete in that there was greater skin temperature at both measured
locations and greater comfort ratings, These authors report that the comfort was inversely related to
mat compressibility.
Cook et al. (1993) used surface EMG to study the recruitment of the anterior tibialis and paraspinal
muscles when standing on linoleum-covered concrete vs. an expanded vinyl 9.5 mm-thick surgical mat.
After subjects stood for two sessions, of two-hour duration, on the mat and on the linoleum, it was
concluded that there were no significant changes in the mean of the rectified EMG signals in either
muscle due to the mats. As in the studies above, subjective data support the use of the mat.
Kim et al. (1994) tested two types of floor mats and a control condition in which subjects stood on
concrete. While these authors observed muscular fatigue, as determined by a shift in the EMG median
frequencies in the gastrocnemius and anterior tibialis muscle, the EMG median frequencies in these
muscles were not affected by the use of floor mats. The median frequency shift in the erector spinae was
reduced when subjects stood on the thinner and more compressible mat. The authors hypothesized that
greater compressibility would have made for a less stable base of support, thereby, requiring more
frequent postural changes in the trunk to overcome the destabilization associated with postural sway.
Thus, the dynamic use of erector spinae muscles to correct for postural sway would facilitate the oxygen
delivery and the removal of contractile by-products through increased blood flow. A further test of this
hypothesis would evaluate whether this motion occurred only in the trunk, or if it occurred in the lower
extremities which did not show the spectral shift due to the floor condition.

Shoe Insoles
It is widely recognized that shoe design plays a critical role in the development of overuse syndromes in
runners (Lehman, 1984; McKenzie et al., 1985; Pinshaw et al., 1984). Moreover, the role of the shoe in

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8-5

controlling lower extremity kinematics has been reviewed by Frederick (1986) and discussed by McKenzie
et al. (1985). Similarly, the use of wedged insoles has been shown to alter the static posture of the lower
extremity (Yasuda and Sasaki, 1987). Sasaki and Yasuda (1987) have shown the use of wedged insoles
to be a good conservative treatment for medial osteoarthritis of the knee in the early stages. These
authors reported that patients with early radiographic stages of osteoarthritis and who were provided a
wedged insole had reduced pain and improved walking ability relative to controls without the insole.
Clearly, the lower extremity disorders reported by runners represent extreme overuse, however, the
treatment and prevention mechanisms may be applicable to occupational settings where employees
must stand, walk, run, or even jump during their normal work activities. Padded insoles have been
investigated for the shock-abating effects on the skeletal system. Loy and Voloshin (1991) used lightweight
accelerometers for measuring the shock waves as subjects walked, ascended and descended stairs, and
jumped off platforms of a fixed height. The peak magnitude of the shock waves during jumping activities
were approximately eight times that seen during normal walking. The results indicated that the insoles
reduced the amplitude of the shock wave by between 9 and 41% depending upon the activity performed.
The insoles were most effective at reducing heel strike impacts and had the largest effect with the jumping
activities.
Milgrom et al. (1985) tested the effects of shock attenuation on the incidence of overuse injuries in
infantry recruits. Earlier studies conducted by fixing accelerometers to the tibial tubercle showed that
soldiers wearing modified basketball shoes had mean accelerations that were 19% less than soldiers
wearing lightweight infantry boots. These authors also found that over the 14 weeks of basic training
the modified basketball shoes reduced the metatarsal stress fractures. However, the tibial and femoral
stress fractures were not affected by the shoes worn. Gardner et al. (1988) compared viscoelastic polymer
insole and a standard mesh insole that were issued by platoon to over 3,000 marine recruits. While the
polymer insole had good shock absorbing properties, the incidence of lower extremity stress injuries
over the 12-week basic training program were unaffected by the insole used.
Several studies have been conducted to evaluate variations in insole materials. Leber and Evanski
(1986) describe the characteristics of the following seven insole materials: Plastazote, Latex foam,
Dynafoam, Ortho felt, Spenco, Molo, and PPT. These authors measured the plantar pressures in 26
patients with forefoot pain. All insole materials reduced the plantar pressure by between 28 and 53%
relative to a control condition. However, PPT, Plastazote, and Spenco were the superior products. Viscolas
and Poron were found to have the best shock absorbency of the five insole materials tested by Pratt et al.
(1986). Maximum plantar pressures were found to be significantly reduced in the forefoot region with
PPT, Spenco, and Viscolas, although the three materials were not significantly different (McPoil and
Cornwall, 1992). In the rear foot region, however, McPoil and Cornwall (1992) report that only the
PPT and the Spenco reduced the maximum plantar pressure relative to the barefoot condition. The
plantar pressure in the rearfoot region was not significantly reduced with the Viscolas. Interestingly,
based on the shock absorbency data from Pratts (1988) 30-day durability test, the resilience of Viscolas,
PPT, and Plastazote could be described as excellent, good, and poor, respectively. Sanfilippo et al. (1992)
also reported the change in foot-to-ground contact area as a function of insole material. Plastazote,
Spenco, and PPT led to a significantly greater contact area than the other materials tested.
In summary, insoles appear to be effective at modifying the lower extremity kinematics and reducing
the peak plantar pressures, although their effectiveness is dependent upon the material used. Additional
research is needed to clarify the effectiveness of insoles in controlling lower extremity stress injuries.
Based on the previous discussion it should be clear that the effectiveness of this control strategy will be
dependent upon shock absorbing capacity, the pressure dispersion, and the durability properties of the
insole materials selected.

The Foot-Floor Interface

Controlling slip and fall injuries requires a multifaceted approach. The foot-floor interface is analogous
to the four-legged stool shown in Figure 8.1. To optimize the postural stability all four legs need to be in

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Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 8.1 The four-legged stool showing the interdependence of the factors affecting postural stability at the footfloor interface.

place and of equal length. The obvious legs are the flooring material and the shoe tread material and
design. The environmental conditions represent the third leg as these affect the coefficient of friction
between the shoe and the floor. And the fourth leg of the stool pertains to the behavior of the individual
wearing the shoe. This behavioral component includes an individuals locomotion pattern, perception
of environmental conditions, and allocation of the attentional resources necessary for adaptive behavior.
If any of the four primary components are missing, at least to some degree, a leg of the stool is cut off by
some random amount. For example, if the environmental conditions result in an oil film on the floor
surface, the stool may still stand on the three remaining legs provided the shoe design and the floor
material are adequate, and that the individual perceives the environmental conditions and adapts his or
her behavior accordingly. Thus, the stool remains standing, although precariously, in spite of a shortened
leg. If the individual did not attend to the environmental conditions the psychomotor leg would have
been shortened, thereby making it unlikely that the stool will remain standing. In summary, the prevention
of lower extremity injuries due to slips and falls requires attention be paid to each component or leg of
the stool responsible for maintaining the bodys stability.
In considering slip and trip prevention it is the dynamic friction of the interface, as opposed to static
friction, which is considered more critical in determining slip potential as most slips occur when the heal
initially contacts the ground (Redfern et al., 1992; Strandberg, 1983). Gronqvist et al. (1992) has
quantified slip resistance by determining the coefftcient of friction between the interacting surfaces and
possible contaminants. These authors reported that the important counter measures against floor
slipperiness are the microscopic porosity and roughness of floor coverings. Flooring materials which
have rough, unglazed, raised patterns, or are made from porous ceramic tiles are best for reducing
slipping hazards in areas which must maintain very high standards for hygiene. In environments where
the hygiene standards can be relaxed, very rough epoxy or acrylic resin floor materials should be used.
Floor surface issues become even more critical on ramps and other inclined work surfaces. Redfern and
McVay (1993) reported that when walking down ramps, the required coefficient of friction increased in
a nearly linear fashion as ramp angle increased. This was due to the high shear forces encountered
during heal strike as an individual walks down a ramp.
Gronqvist and Hirvonen (1994) studied slip resistance properties of footwear on iced surfaces. They
found that the shoe material significantly affected the slip resistance. Shoe heels and soles constructed
from thermoplastic rubber with a large cleated area were best for dry ice conditions (-10 C). Very few
of the shoes tested functioned well on wet ice (0 C) where there is a boundary layer of water on top of
the ice. In fact, the shoes which worked best for dry ice conditions were among the worst when tested in
the wet ice condition. Shoes with the sharpest cleats yielded the greatest friction readings under this
condition. Hardness of the heel and sole material was not a significant factor on wet ice.
Little consensus is found in sole hardness data, and what differences exist are not of practical
significance (Leclercq, 1994). In general, microcellular PU (polyurethane) heels and soles are

Ergonomic Principles Applied to the Prevention of Injuries to the Lower Extremity

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recommended, although footwear showed less of an effect on the kinetic coefficient of friction than did
variations in floor surfaces (Gronqvist et al., 1992). Relative to rubber soles and heels, Manning et al.
(1985) reported that boots with microcellular polyurethane (PU) soles and heels better resisted polishing
caused by smooth, wet, or oily floors; had a longer life; and had a greater average coefficient of friction.
The COF of the PU improved over time, indicating that the initial smooth surface of the boots should be
roughened prior to use. Tisserand (1985) recommends avoiding the use of micro-treads or small
bumps. However, tread design and material are not independent factors when it comes to the coefficient
of dynamic friction. Leclercq et al. (1994) stress that the ridges in the tread need to be as sharp as
possible to wipe away contaminants on the surface. In addition, these authors point out that the tread
design needs to provide channels for the surface contaminants to flow through. Slipping risk is greatest
at heel-strike, and therefore, the heel of the shoe requires considerable attention. There is controversy
regarding whether the use of a bevelled heel to increase contact surface area is superior to the use of a
small contact surface that would result in high contact pressure (Leclercq et al., 1994).
Tisserand (1985) has promoted the concept of a mental model whereby an individual has constant
input as to the friction available from the surface being walked upon. The model is updated as new
information is received indicating a change in the surface conditions. Slips occur where there is a
discrepancy between the mental model of the surface and the actual conditions. Thus, as Tisserand
(1985) points out: The risk of slipping lies more in the gradient of the friction coefficient of the surface
than in its absolute value: such as when in a car, a small patch of ground with a low coefficient (an
isolated patch of ice, for example, on a large surface with a high coefficient of friction) is more dangerous
than a surface with a medium but constant coefficient of friction (pp. 1039).
Swensen assessed the subjective judgments of surface slipperiness by having groups of iron workers
and students walk across steel beams. The subjects were asked to rank the slipperiness of four types of
steel coatings and four levels of surface contaminant: none, water, clay, plastic covering oil. Static coefficient
of friction (COF) values ranged between .98 and .20. For the experienced and inexperienced subjects the
correlation between the subjective surface ratings and the actual COF measured following the test were
.75 and .90, respectively. The subjects exposed to the very slippery conditions (COF=.20) created by the
oil and plastic compensated by shortening their stride length, thereby lessening the foot velocity and
shear forces, and maintained the bodys center of gravity within the smaller region of stability. Thus,
people can detect the COF and adapt their gait accordingly. When this adaptation fails to take place, an
individual is much more likely to slip and possibly fall.
Ideally, with the perfect shoe-floor interface, one with no environmental contaminants, the individuals
behavior would be not be a factor. But in few cases would this exist, and then, even a small fluctuation
in the environment would be enough to disrupt the balance of the now three-legged stool. Therefore,
administrative control measures need to be considered as a means for maintaining the behavior necessary
for stable work postures. Employees should be trained to recognize where slippery conditions are likely
within a facility, and that they be alert to changing environmental conditions. Further, employees should
be encouraged to report maintenance problems with machines that affect the flooring conditions.

Stair Design
Pauls (1985) reports that only 6% of stair accidents entail slips, more often accidents are due to overstepping. This author suggests that the overstepping occurs because the individual descending the
stairs does not accurately perceive the stair width (also known as tread length). Thus, the foot is placed
too far forward on the step. This scenario accounts for 19% of all stair accidents. This work highlights
the interplay between engineering design factors (stair size) and behavioral factors. Research has suggested
that stairs should have risers no higher than 178 mm (7 inches) and treads no shorter than 279 mm (11
inches).
A secondary issue in stair design is the complex effect of visual distractions. Pauls (1985) reported
that when visual distractions were present people actually focused harder on descending the stairs.
When no distractions were present people exhibited less caution. Similarly, patients commonly reported

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Occupational Ergonomics: Engineering and Administrative Controls

that their falls leading to femoral neck fractures were initiated with missing a step down, for example,
unexpectedly stepping off a curb (Citron et al., 1985). This suggests that when the brain recognizes the
potential distractions attention resources are allocated to the task at hand, whereas without some overt
distraction the brain may allocate adequate attentional resources, or it may not. Archea (1985) has
stressed that an older population that may not have the perceptual and motor capabilities found in
younger individuals are more vulnerable to accidents on stairs. These findings suggest that the effects of
distractions around stairs changes through the aging process.

Help for Those in Kneeling Postures

Sharrard (1963) reported that there was no relationship between the type of knee pads used and the
incidence of beat knee in miners. This author recorded peak pressures on the order 35.7 kg per square
cm as simulated mining tasks were performed. These compression forces were shown to vary widely
throughout the 2.5 second cycle time for a shoveling task. Unfortunately, the author had no
instrumentation capable of determining the shear forces and the torsional moments placed on the knee
during the simulated tasks. At the time of Sharrards paper a bursa pad had been designed that
allowed perspiration to escape, pushed coal particles away from the skin, and provided satisfactory
cushioning. Although no control group was used, the author reported that of the 24 previously affected
men selected to test the pad under working conditions only two reported a recurrence of beat knee after
a 12-month period.
Ringen et al. (1995) reported on a new tool to reduce the knee and back trauma in those who tie
rebar rods together in preparation for pouring concrete. No longer will concrete workers need to kneel
or stoop for extended periods to interconnect the iron rods as this tool allows the operator to work in a
standing posture.
Powered carpet stretching tools are available to remove the repeated trauma experienced by carpet
layers. However, their widespread implementation depends upon educating flooring workers on the
trade-offs between the additional time necessary to operate the tool and the knee disorders associated
with the conventional technique.

8.3 Summary
Ergonomic texts historically have focused relatively little attention on the prevention of lower extremity
disorders or the accommodation of individuals returning to work who have experienced a lower extremity
disorder. In part this may be due to an underappreciation of the frequency and severity of occupational
lower extremity disorders. Unlike many back or upper extremity disorders which have their origins in
the repeated stresses placed on muscular, tendinous, and ligamentous tissues, many of the occupational
lower extremity disorders occur through direct compression of the body tissues by a surface in the
environment. As a result, the occupational lower extremity disorders often involve cartilaginous tissue
and bone. Therefore, accommodation and prevention of these disorders occurs primarily through the
optimizing the bodys contact with surfaces in the environment. This chapter has illustrated some of the
key ways in which this can be accomplished.

References
Anderson, E.G. (1990). Fatigue fractures of the foot. Injury, 21, 275279.
Anderson, J.J. and Felson, D.T. (1988). Factors associated with osteoarthritis of the knee in the first
national health and nutrition examination survey (HANES I). American J. of Epidemiology, 128,
179189.
Andersson, G.B.J. (1991). The epidemiology of spinal disorders, in [Link] (Ed.) The Adult Spine:
Principles and Practice. New York: Raven, 107146.
Andres, R.O., OConner, D., and Eng, T. (1992). A practical synthesis of biomechanical results to

Ergonomic Principles Applied to the Prevention of Injuries to the Lower Extremity

8-9

prevent slips and falls in the workplace, in [Link] (Ed.) Advances in Industrial Ergonomics and
Safety IV, London: Taylor & Francis, 10011006.
Archea, J.C. (1985). Environmental factors associated with stair accidents by the elderly. Clinics in
Geriatric Medicine, 1, 555569.
Bhattacharya, A., Mueller, M., and Putz-Anderson, V. (1985). Traumatogenic factors affecting the knees
of carpet installers. Applied Ergonomics, 16, 243250.
Citron, N. (1985). Femoral neck fractures: are some preventable? Ergonomics, 28, 993997.
Cook, J., Branch, T.P., Baranowski, T.J., and Hutton, W.C. (1993). The effect of surgical floor mats in
prolonged standing: an EMG study of the lumbar paraspinal and anterior tibialis muscles. J.
Biomedical Engineering, 15, 247250.
Cowan, D.N., Jones, B.H., Frykman, P.N., Polly, D.W., Harman, E.A., Rosenstein, R.M., and Rosenstein,
M.T. (1996). Lower limb morphology and risk of overuse injury among male infantry trainees.
Medicine and Science in Sports and Exercise, 28, 945952.
Frederick, E.C. (1986). Kinematically mediated effects of sport shoe design: a review. Journal of Sports
Sciences, 4, 169184.
Gallagher, S. and Unger, R.L. (1990). Lifting in four restricted lifting conditions. Applied Ergonomics,
21, 237245.
Gardner, L.I., Dziados, J.E., Jones, B.H., and Brundage, J.F. (1988). Prevention of lower extremity stress
fractures: a controlled trial of a shock absorbent insole. American Journal of Public Health, 78,
16631567.
Giladi, M., Ahronson, Z., Stein, M., Danon, Y.L., and Milgrom, C. (1985). Unusual distribution and
onset of stress fractures in soldiers. Clinical Orthopaedics & Related Research, 192, 142146.
Giladi, M., Milgrom, C., Simkin, A., and Danon, Y. (1991). Stress fractures. Identifiable risk factors.
American Journal of Sports Medicine, 19, 647652.
Gronqvist, R., Hirvonen M., and Skytta, E. (1992). Countermeasures against floor slipperiness in the
food industry, in [Link] (Ed.) Advances in Industrial Ergonomics and Safety IV, London: Taylor
& Francis, 989996.
Gronqvist, R. and Hirvonen, M. (1994). Pedestrian safety on icy surfaces: Anti-slip properties of footwear,
in [Link] (Ed.) Advances in Industrial Ergonomics and Safety VI, London: Taylor & Francis,
315322.
Hinnen, P. and Konz, S. (1994). Fatigue mats, in [Link] (ed.) Advances in Industrial Ergonomics
and Safety VI, London: Taylor & Francis, 323327.
Jordaan, G. and Schwellnus, M.P. (1994). The incidence of overuse injuries in military recruits during
basic military training. Military Medicine, 159, 421426.
Kim, J.Y., Stuart-Buttle C., and Marras, W.S. (1994). The effects of mats on back and leg fatigue.
Applied Ergonomics, 25, 2934.
Kuorinka, I., Hakkanen, S., Nieminen, K., and Saari, J. (1978). Comparison of floor surfaces for standing
work, in [Link] and [Link] (Eds.) Biomechanics VI-B, Proceedings of the Sixth
International Congress of Biomechanics, Baltimore, University Park Press, 207211.
Kohatsu, N.D. and Schurman, D.J. (1990). Risk factors for the development of osteoarthrosis of the
knee. Clinical Orthopaedics and Related Research, 261, 242246.
Kuorinka, I, Hakkanen, S, Nieminen, K., and Saari, J. (1978). Comparison of floor surfaces for standing
work, in [Link] and [Link] (Eds.) Biomechanics VI-B, Baltimore: University Park Press,
207210.
Leber, C. and Evanski, P.M. (1986). A comparison of shoe insole materials in plantar pressure relief.
Prosthetics and Orthotics International, 10, 135138.
Leclercq, S., Tisserand, M., and Saulnier, H. (1994). Slip resistant footwear: A means for the prevention
of slipping, in [Link] (Ed.) Advances in Industrial Ergonomics and Safety VI, London: Taylor
& Francis, 329337.
Lehman, W.L. (1984). Overuse syndromes in runners. American Family Physician, 29, 157161.
Lindberg, H. and Axmacher, B. (1988) Coxarthrosis in farmers. Acta Orthop. Scand., 59, 607.

8-10

Occupational Ergonomics: Engineering and Administrative Controls

Lindberg H. and Montgomery, F. (1987). Heavy labor and the occurrence of gonarthrosis. Clinical
Orthopaedics and Related Research, 214, 235236.
Linenger, J.M. and Shwayhat, A.F. (1992). Epidemiology of podiatric injuries in US Marine recruits
undergoing basic training. Journal of the American Podiatric Medical Association, 82, 269271.
Loy, D.J. and Voloshin, A.S. (1991). Biomechanics of stair walking and jumping. Journal of Sports
Sciences, 9, 136149.
Manning, D., Jones, C., and Bruce, M. (1985). Boots for oily surfaces. Ergonomics, 28, 10111019.
McKenzie, D.C., Clement, D.B., and Taunton, J.E. (1985). Running shoes, orthotics, and injuries. Sports
Medicine, 2, 33447.
McGlothlin, J.D. (1996). Ergonomic Interventions for the Soft Drink Beverage Delivery Industry. U.S.
Department of Health and Human Services (NIOSH) Publication No. 96109.
McPoil, T.G. and Cornwall, M.W. (1992). Effect of insole material on force and plantar pressures
during walking. Journal of the American Podiatric Medical Association, 82, 412416.
Milgrom, C., Finestone, A., Shlamkovitch, N., Wosk, J., Laor, A., Voloshin, A., and Eldad, A. (1992).
Prevention of overuse injuries of the foot by improved shoe shock attenuation. A randomized
prospective study. Clinical Orthopaedics & Related Research, 281, 189192.
Myllymaki, T., Tikkakoski, T., Typpo, T., Kivimaki, J., and Suramo, I. (1993). Carpet layers knee. An
ultrasonographic study. Acta Radiol., 34, 496499.
Pinshaw, R., Atlas, V., and Noakes, T.D. (1984). The nature and response to therapy of 196 consecutive
injuries seen at a runners clinic. South African Medical Journal, 65, 291298.
Pratt, D.J., Rees, P.H., and Rodgers, C. (1986). Assessment of some shock absorbing insoles. Prosthetics
& Orthotics International, 19, 4345.
Pratt, D.J. (1988). Medium term comparison of shock attenuating insoles using a spectral analysis
technique. Journal of Biomedical Engineering, 10, 426429.
Redfern, M.S. and Bidanda, B. (1992). The effects of shoe angle, velocity, and vertical force on shoe/
floor slip resistance, in [Link] (Ed.) Advances in Industrial Ergonomics and Safety IV, London:
Taylor & Francis, 9971000.
Redfern, M.S. and McVay, E.J. (1993). Slip potentials on ramps, in Proceedings of the Human Factors
and Ergonomics Society 37th Annual Meeting, 2, 701703.
Ringen, K., Englund, A., and Seegal, J. (1995). Construction workers, in [Link], and [Link]
(Eds.) Occupational Health: Recognizing and Preventing Work-Related Disease, Boston: Little,
Brown, and Company, 685701.
Rys, M. and Konz, S. (1990). Floor mats, in the Proceedings of the Human Factors Society 34th Annual
Meeting, 1, 575579.
Rys, M. and Konz, S. (1989). An evaluation of floor surfaces, in the Proceedings of the Human Factors
Society 33rd Annual Meeting, 1, 517520.
Sanfilippo, P.B., Stess, R.M., and Moss, K.M. (1992). Dynamic plantar pressure analysis. Comparing
common insole materials. Journal of the American Podiatric Medical Association, 82, 502513.
Sasaki. T. and Yasuda, K. (1987). Clinical evaluation of the treatment of osteoarthritic knees using a
newly designed wedged insole. Clinical Orthopaedics & Related Research, 221, 181187.
Sharrard, W.J.W. (1963). Aetiology and pathology of beat knee. British Journal of Industrial Medicine,
20, 2431.
Strandberg, L. (1983). On accident analysis and slip-resistance measurement. Ergonomics, 26, 1983.
Swensen, E.E., Purswell, J.L., Schlegel, R.E., and Stanevich, R.L. (1992). Coefficient of friction and
subjective assessment of slippery work surfaces. Human Factors, 34, 6777.
Tanaka, S., Smith, A.B., Halperin, W., and Jensen, R. (1982). Carpet-layers knee. The New England J.
of Medicine, 307, 12761277.
Tellier, C. and Montreuil, S. (1991) Pain felt by workers and musculoskeletal injuries: assessment relating
to tufting shops in the carpet industry, in [Link] and [Link] (Eds.) Designing for Everyone,
1, 287289.
Thun, M., Tanaka, S., Smith, A.B., Haperin, W.E., Lee, S.T., Luggen, M.E., and Hess, E.V. (1987).

Ergonomic Principles Applied to the Prevention of Injuries to the Lower Extremity

8-11

Morbidity from repetitive knee trauma in carpet and floor layers. British Journal of Medicine, 44,
611620.
Tisserand, M. (1985). Progress in the prevention of falls caused by slipping. Ergonomics, 28, 1027
1042.
Torner, M., Zetterberg, C., Hansson, T., and Lindell, V. (1990). Musculo-skeletal symptoms and signs
and isometric strength among fishermen. Ergonomics, 33, 11551170.
Torner, M., Almstrom, C., Karlsson, R., and Kadefors, R. (1991). Biomechanical calculations of musculoskeletal load caused by ship motions, in combination with work, on board a fishing vessel, in
[Link] and [Link] (Eds.) Designing for Everyone, 1, 293295.
Village, J., Morrison, J.B., and Leyland, A. (1991). Carpetlayers and typesetters ergonomic analysis of
work procedures and equipment, in [Link] and [Link] (Eds.) Designing for Everyone, 1,
320322.
Vingard, E., Alfredsson, L, Goldie, I., and Hogstedt, C. (1991). Occupation and osteoarthrosis of the
hip and knee: A register-based cohort study. International Journal of Epidemiology, 20, 1025
1031.
Vingard, E., Alfredsson, L., Fellenius, E., and Christer, H. (1992). Disability pensions due to musculoskeletal disorders among men in heavy occupations. Scand. Journal Social Med., 20, 3136.
Yasuda, K. and Sasaki, T. (1987). The mechanics of treatment of the osteoarthritic knee with a wedged
insole. Clinical Orthopaedics & Related Research, 215, 162172.

9
Ergonomics of the Foot
9.1 Foot/Leg
9.2
9.3

Anatomy Physiology Dimensions

Activities of the Foot
Standing Walking Running Stepping
Accidents
Falls Causes of Falls Solutions for Falls

9.4 Fatigue/Comfort
Stephan Konz
Kansas State University

9.5

Walking Standing
Foot Controls
Pedals Switches

91
95
96

910
912

This chapter is divided into five sections. Section 1 (Foot/Leg) gives the anatomy, physiology, and
dimensions of the foot. Section 2 (Activities) describes the activities of standing, walking, running, and
stepping. Section 3 (Accidents) discusses falls, their causes and solutions. Section 4 (Fatigue/Comfort)
discusses walking and standing. Section 5 (Foot Controls) briefly describes pedals and switches.

9.1 Foot/Leg
Anatomy
Figure 9.1 shows the bones of the foot and ankle. The toes (foot fingers) are divided into metatarsals
and three phalanges (except for the big toe, which only has two phalanges). In supporting the body, the
calcaneus (heel) supports 50% of the weight, the 1st and 2nd metatarsal 25%, and the 3rd, 4th, and 5th
metatarsal 25%. In between are two arches: (1) the medial arch (calcaneus, the talus, the navicular, the
cuneiform bones, and the 1st, 2nd, and 3rd metatarsals) and (2) the lateral arch (calcaneus, talus,
cuboid, and the 4th and 5th metatarsals).
Under the heel (calcaneus) is a very important shock absorber, the heel pad (about 1.8 cm thick). The
bottom of the calcaneus is not spherical but has two small mountains; the pad reduces the pressure on
these mountains, and thus on the ankle, knee, and back.
The foot is connected to the ankle with a mortise and tenon joint. The vertical leg of the mortise is
short on the outside (lateral side); in addition, the ligaments holding the bottom of the fibula (lateral
malleolus) to the talus and calcaneus are relatively weak. In contrast, the vertical leg of the inside (medial)
mortise is longer, and the ligaments holding the bottom of the tibia (medial malleolus) to the talus are
relatively strong.
Inward rotation (inversion) of the foot tends to pull the ligaments from the bone; with proper treatment,
healing is usually complete in about 3 weeks. There is a danger that the injured person may not seek
medical advice even with a complete tear of the ligaments (connecting either the malleolus and the talus
or the tibia and fibula). Then there would be need for surgical repair and rigid fixation in a cast for 2 to
3 months.

0-8493-1800-9/03/$0.00+$1.50
2003 by CRC Press LLC

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Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 9.1 The foot and ankle. The right foot is viewed from below (top left) and the outside (top right); the left
ankle (bottom) is viewed from the front.

External rotation (eversion) of the foot tends to break one of the malleoli bones (vertical part of the
mortise). These serious injuries tend to be recognized and the injured person goes to a physician.
Approximately 80% of all foot fractures involve the toes; almost all of them could be prevented by
safety shoes since they lie within the area protected by the metal toe cap (Rowe, 1985).
Three venous systems drain the lower limbs: (1) a deep central system drains the muscles, (2) a
superficial system drains the foot and the skin of the leg, and (3) a perforating system connects the deep
and superficial systems.

Physiology
The veins are the bodys blood storage location. If the legs dont move, the blood from the heart tends
to go down to the legs and stay there (venous pooling). This causes more work for the heart, as, for a
constant supply of blood, when there is a lower ml of blood per beat, then there must be more beats.
Venous pooling causes swelling of the legs (edema) and varicose veins. The foot swelling during stationary
seated desk work can be overcome by modest leg activity (such as rolling the chair about the workstation)
(Winkel and Jorgensen, 1986).
Venous pressure in the ankle of sedentary people is approximately equal to hydrostatic pressure from
the right auricle. Pollack and Wood (1949) gave a mean ankle venous pressure of 56 mmHg for sitting
and 87 for standing. Nodeland et al. (1983) gave 48 for sitting and 80 for standing. Pollack and Wood
reported walking drops ankle venous pressure to about 23 mmHg (Nodeland et al. reported 21) in

Ergonomics of the Foot

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TABLE 9.1 Selected Dimensions (cm) of Nude U.S. Adult Civilians

The percentages show the dimension as a percent of stature height.

Shoes add 25 mm height for males and 15 mm for females. Shoes add
.9 kg to body weight.
Source: Konz, S. 1995. Work Design: Industrial Ergonomics, 4th
ed., p. 111. Publishing Horizons, Scottsdale, AZ. With permission.

about ten steps. The fall occurs as the calf muscles contract in taking the next step before venous filling
has been completed; thus additional blood is pumped out of the leg, causing a further drop in pressure
when the calf muscles relax. The drop stabilizes in about ten steps when the incoming flow to the vein
from the capillaries equals the flow out of the leg. Thus, walking can partially compensate for posture;
for example, Nodeland et al. reported standing bench work (i.e., with occasional steps around the area)
had ankle pressure approximately equal to sitting at a desk (48 mmHg).
Because of vasoconstriction, foot skin temperature (without shoes) usually is the lowest body skin
temperature. Normal skin foot temperature = 33.3C for males but 31.2 for females (Oleson and
Fanger, 1973).

Dimensions
Table 9.1 gives some dimensions for U.S. adults. A large portion of the variation in human stature is in
leg length; the torso is relatively constant in height. Figure 9.2 shows the mean difference, when standing,
between the inside of the two feet is about 107 mm. The distance between foot centerlines is about 107
+ 90 = 197 mm (200 mm in round numbers). The distance between outside edges is 107 + 90 + 89 = 286
(300 mm in round numbers). Yet mean height for males is 1756 mm! Thus there is a base of only 200 to
300 mm for a structure of 1756 mm.
The mean pressure (Rys and Konz, 1994) on the feet can be estimated from:
(9.1)

where
MP = mean pressure, kg/cm2
WT = body weight, kg
Thus a 70 kg person would have an MP = .33 kg/cm2. But the peak pressure could be much higher (say
10 kg/cm2). Diabetics (who may have neuropathic feet) can have pressures of 20 to 30 kg/cm2, leading to
recurrent ulceration and eventual amputation (Boulton et al., 1984).
There is no significant difference between the left and right foot. However, for specific individuals, there
often is considerable difference between the left and right footespecially in width (see Figure 9.3.)
The technical name for differences in leg length in the same person is leg length discrepancy (LLD).
Contreras et al. (1993), summarizing studies with N = 2377, reported that 40% of people had LLD 5
mm, 30% had LLD 9 mm, 20% had LLD 11 mm, and 10% had LLD 14 mm.
Weight of leg segments (Clauser et al., 1969), as a percent of body weight, are: 1.47 for foot, 4.35 for
calf, and 10.27 for thigh; a total leg is 16.10 and both legs are 32.2. For example, the weight of both legs
for a 70 kg person would average 70 (.322) = 22.5 kg.

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FIGURE 9.2 Footprint dimensions in mm (males above line; females below line); areas in mm2; angles in degrees
(Rys and Konz, 1994). Toe area is 10% of contact area. They stood with the right foot slightly (68 mm) ahead of the
left foot. The left foot (for males) averaged 7.3 to the left of the medial plane; the right foot averaged 9.1 to the
right.

FIGURE 9.3 Distributions of left/right percentage of 84 Americans for foot length, width, circumference and volume
(Rys and Konz, 1994). Although the mean of the left does not differ significantly from the right (i.e., the ratio does
not differ from 100), for an individual the left can differ from the right.

Ergonomics of the Foot

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When people stand at a work surface, there needs to be an indentation for their toes so they can stand
close to the worksurface. Rys and Konz (1994) recommend a space at least 150 mm deep, 150 mm high,
and 500 mm wide.

9.2 Activities of the Foot

Standing
During standing, the legs will generally move occasionally. Satzler et al. (1993) recorded foot movements
for 120 min of standing; people moved a foot approximately every 90 s.

Walking
When walking, the activity of one leg has a shorter swing phase (when the foot is being passed forward)
and a longer support (stepping, contact) phase (when the foot is on the ground). The support phase
starts at heel strike and ends at toe-off; it has an early, passive section and a later active (propulsion)
section (Davis, 1983).
At heel strike, the forward-moving heel hits the ground (causing deceleration). Continued forward
motion of the body results in the forefoot contacting the ground; propulsion (acceleration) begins. The
heel rises and the foot is pushed backward under the body. This tendency is resisted by friction under the
sole; the body is propelled forward. The foot is everted, increasing forefoot contact area on the inner
side, until only the skin around the big toe is in ground contact. Finally, contact ceases and the cycle
repeats. At heel strike, horizontal velocity decreases from about 450 cm/s to 20 cm/s; heel angle to the
floor changes from about 20 prior to heel contact to 0 at 100 ms after contact (Redfern and Rhoades,
1996). During a slip, instead of stopping, the heel continues to move and the leading foot moves out in
front of the body.
Since the swing phase is shorter than the support phase, heel strike of the opposite limb occurs during
the propulsion section of the support phase.
The length of stride (L) divided by stature height (h) varies linearly with velocity; L/h = .67 at v = .8
m/s and L/h = .9 at 1.7 m/s (Alexander, 1984).

Running
Walking changes to running, for normal size adults, at about 2.5 m/s (6 miles/h) (Alexander, 1984) since
it uses less energy (for the same speed). Running differs from walking in that both feet are off the ground
for part of the stride. In addition, the heel strike should be renamed the foot strike, since the initial
contact probably will be forward of the heel. Peak force is about 3body weight at about .1 s after
contact. For walking, heel touchdown to toe push-off is .48 s, while, for running, the average contact
duration is .29 s (Scanton and McMaster, 1976). After foot strike (usually on the outside edge of the
foot), the foot rolls inward and flattens out (pronation). Then the foot rolls through the ball and rotates
outward (supination).

Stepping
Descending stairs demands a gait quite different from ascent (Templer, 1992). For descent, the leading
foot swings forward over the nosing edge and stops its forward motion when it is directly over the tread
below; the toe is pointed downward. Meanwhile the heel of the rear foot begins to rise, starting a
controlled fall downward toward the tread. The heel of the forward foot then is lowered and the weight
transferred to the forward foot. The rear foot then begins to swing forward. We tend to hold our center
of gravity as far back as possible by leaning backward. Problems are overstepping the nosing with the
forward foot, catching the toe of the forward foot, and snagging the heel of the rear foot on the nosing
as it swings past. Falls tend to be down the stairs.

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Occupational Ergonomics: Engineering and Administrative Controls

For ascent, the leading foot has a toe-off, swing, and first contact with the upper step. The foot is
roughly horizontal. The ball of the foot is well forward on the tread; the heel may or may not be on the
tread. The rear foot then rises on tiptoe, pushing down and back. The rear leg then begins the swing
phase. The primary problem is catching the toe, foot, or heel of either foot on the stair nosing. Another
problem is slipping by the rear foot when it pushes backward. Falls tend to be upward.

9.3 Accidents
Falls
The annual death rate from falls in the United States is about 11,700; about 6,500 of these are in the
home (especially affecting elderly women). About 15% of the population will have hospital treatment in
their lifetime because of injuries from a stair accident (Pauls, 1985). Occupational exposures result in
about 1,500 deaths and 300,000 injuries (Leamon, 1992). In industrial fatalities, falls account for about
12%, which is greater than the total for electrical current, fires, burns, and poisons of all types (Leamon,
1992). Of workers injured in falls from heights, about 20% die (Eisma, 1990).
Not all underfoot accidents result in falls, and not all falls result in a lost-time injury. Some falls result
in no lost time, some result in sprains and strains, some in broken bones, and some in death. In addition,
falls often are not recorded by accident recording procedures (Leamon, 1992). Thus the accident reports
tend to drastically underestimate the number of falls. It needs to be emphasized that the risk of a fall
varies very much with occupation; all people do not have a dry, level indoor floor. Construction workers,
cleaning personnel, transportation workers, and restaurant serving personnel have higher risks (Chaffin
et al., 1992).
Andersson and Lagerlof (1983) analyzed 121,000 occupational accidents resulting in injuries; 20,600
had a fall. Falls on the same level were 2/3 and falls between levels were 1/3. For the same level, the main
preevents were slipping (55%) and tripping (19%). (Manning et al. (1988) reported, for falls on the
same level, 62% for slips and 17% for trips.) For falls to a lower level (e.g., from stairs, ladders, roofs,
vehicles), the main pre-events were loss of support of underlying surface (28%), slipping (28%), and
stepping-on-air (8%). The lower-level problem is focused in job trades such as roofers, painters, and
maintenance workers. Since the fall has a greater distance, the body velocity and resulting deceleration
become greater.
Falls which occur when the person is carrying something are especially dangerous. The object carried
decreases stability as a function of the torque above the ankle (weightobject height above ankle). Other
problems are that the arms cannot be used for balance (to prevent a fall), to grab a railing, or to break
the fall impact.

Causes of Falls
Falls can occur from slips (unexpected horizontal foot movement), trips (restriction of foot movement),
and stepping-on-air (unexpected vertical foot movement). Loss of balance and falls can occur without a
slip, trip, or stepping-on-air. Examples would be from alcohol or drugs, fainting, etc. Or, people who fall
may have blood pressure problems or foot problems (Gabel et al., 1985).
The elderly may be more likely to fall because of deterioration in postural control mechanisms and
decrements in visual acuity, strength, endurance, reaction time, and motor control. Furthermore, on falling,
the elderly are more likely to sustain a bone fracture (due to osteoporosis) (Maki and Fernie, 1990).

Slips
Slips primarily occur during foot pushoff and heel strike. During pushoff, the person falls forward (less
common and less dangerous). In addition, during pushoff, most of the weight has already been transferred
to the other foot. If a slip occurs during heel strike, the person falls backward. The critical time is .05 to
.1 s after heel strike. Leamon (1992) defines a microslip as a slip less than 2 cm, a slip as 8 to 10 cm, and
a slide as uncontrolled movement of the heel. Microslips occur very often and normally are not perceived

Ergonomics of the Foot

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TABLE 9.2 Minimizing Slips and Slip Effects

by the person. A slip is perceived and the person typically jerks the upper body, moves the arms, etc.
but does not fall. A slide involves loss of control and usually a fall.
During a slip, there normally is a lubricant (water, oil, grease, dust, ice, snow) either on the surface
or on the shoe heel (Leclercq et al., 1994).
Slips can also occur, with stationary feet, during pushing and pulling. Although the feet slip, there
does not tend to be a fall and injury.
Slips also can occur when the ground slopes (front to back or side to side). Examples are ramps
and ladder rungs. When moving a cart up or down a ramp, stay above the cart to prevent injury from the
cart if it gets loose. Outdoor walkways often are sloped, have poor illumination, and have water and
ice as lubricants.
In the special outdoor circumstances of snow and ice, slipping can be very common; in Finland,
slipping outdoors is 10 times more common in winter (Gronqvist and Hirvonen, 1995). The most
danger occurs when the ice is wet (i.e., close to the freezing point) as the water is a lubricant. For this
situation, the best shoes have a soft heel/sole (Shore A hardness <60) made of thermoplastic rubber and
exhibiting a large apparent contact area (good tread). Cleats (spikes, studs) are effective if they can
penetrate the ice (i.e., if ice is close to the freezing point); if they cannot penetrate (i.e., ice is too hard (say
at -10 C), then shoes with spikes are very slippery. Strewing sand on ice is effective on wet ice (i.e., close
to freezing) but has relatively little effect on dry ice. Adding salt to melt ice may work if the temperature
is close to freezing; if the water then evaporates, this is good, but if the result is just a lubricant added to
the ice, the result is bad.
Table 9.2 summarizes how to reduce slips.

Trips
Trips occur during swing. As the foot swings forward, it hits an obstacle and the person falls forward.
Thus, in contrast to slips where the problem is excessive horizontal leg movement, with trips the problem
is lack of leg movement. Outdoor trips often occur from uneven surfaces (walkways, parking lots)
which the person expects to be even. Indoor trips tend to be from objects on the floor or stairs. Usually
there is a visual problem.

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Occupational Ergonomics: Engineering and Administrative Controls

Stepping-On-Air
Stepping-on-air occurs when the foot has unexpected vertical movement. This can occur on steps when
the distance between stairs is unequal; it can occur when there is a hole in the ground; it can occur when
there is no ground (i.e., cliff, edge-of-scaffold, unexpected step, step on spiral stairs, unexpected curb
or ramp). Very commonly, stepping-on-air occurs with single steps (small changes in elevation) such
as curbs or one-step changes in floor level. Steps descending from large trucks and off-road vehicles
often present problems. On steps, the fall usually occurs when descending; the fall can be for a considerable
distance.
In some cases, the surface is there initially but breaks or moves (step breaks, floor mat slides, a chair
used as a stepstool moves). Ladder feet need to be non-slip as slipping of the ladder base is the most
common pre-event for portable ladder accidents (Alexsson and Carter, 1995). Often stepping-on-air has
a visual cause.

Solutions for Falls

The goals are to: (1) prevent the fall and (2) reduce the consequences of the fall.

Prevent the Fall

Scaffolds and work platforms should have a waist-high (107 cm) guardrail as well as a 10 cm high
toeboard (reduces slips over the edge as well as reducing falling objects). The top of the guardrail should
discourage sitting.
Since the primary problem on stairs is overstepping (Pauls, 1985), for safe stairs: (1) have easily
visible steps, (2) provide treads that are long enough, and (3) provide handrails that are both within
reach and graspable.
Visual solutions consider both the quantity of light and the quality of light. Note that not everyones
vision is perfect. For example, consider people not wearing their glasses, vision of elderly, the out of
focus of steps when people wearing bifocals descend stairs, etc.
The quantity of light typically is increased with fixed sources (ceiling lights, street lights, etc). But
lamps fail; the resulting lack of light is especially critical for stairs. One solution is to have two lamps
illuminate critical areas. Portable sources such as flashlights are a temporary solution. Too much light
causes glare; solutions include nonreflecting surfaces and glare shields for both natural and artificial
illumination.
The quality of light is also important. Ideally, the light should give moderate shadows because shadows
aid depth perception. Depth perception is improved by using multiple sources and considering the
orientation (direction) of the light. Camouflage consists in obliterating contrasts; we are concerned with
anticamouflage. Contrast is especially important on steps.
Because walking is automatic, attention must be drawn to steps, especially if the step is camouflaged
so there is an ambush. Do not distract attention from a stairs by providing a view as a person
begins the descent. Call attention to steps by changing the color of the floor (e.g., red carpet on stairs vs.
green carpet on approaches), having a handrail (especially for one-step stairs), changing wall color on
stair walls (e.g., paint changes color and descends at the angle of the stairs), having the handrail color
contrast with the wall and stair, and avoiding carpet patterns which confuse depth perception (e.g.,
narrow strips with strong contrast).
For stairs, the key for friction is the nosing, not the tread. Thus, have a high coefficient of friction for
the nosing. Outdoor stairs often are lubricated by rain and snow. Such stairs should have a wash (slope
of less than 1:60) to permit water to drain. Perhaps a roof is feasibleeven if it doesnt give 100%
protection. Prevent water (from the ground or a building) from draining onto the stairs.
Handrails on stairs help prevent falls. The handrail should permit a power grip (11 to 13 cm
circumference), have a clearance from the wall of about 3.8 cm, and be 89 to 97 cm above the stair

Ergonomics of the Foot

9-9

(Konz, 1994). A handrail must be within reaching distance; at a minimum there should be a handrail on
the right side descending. For detailed information on stair design, see Templer (1992) and NFPA (1991).
For mounting/dismounting vehicles, use the three-contact rule (at each phase of mounting/dismounting,
at least three limbs should maintain contact with steps or handles at the same time).
Ramps for people should have a maximum angle of about 5. If handtrucks are pushed up the ramp,
there should be a landing at least every 3 m in elevation. Have a nonskid surface in the center of each
lane. Ramps should have handrails and, if used by vehicles, heavy curbs. If vehicles use a ramp exposed
to rain or snow, have a 60 cm strip of abrasive metal plate in the track of each wheel; attach it to the
concrete with countersunk holes and flat-head expansion screws. Maximum ramp angles for vehicles
are 3 for a power-operated hand truck, 7 for a powered platform truck, 10 for a low-lift pallet-skid
truck, 10 for an electric fork truck, and 15 for a gasoline fork truck (Konz, 1994).
Dont use the hands to carry objects while on ladders and stairs.
If a person knows the surface is slippery, walking behavior can be changed. A short stride length
reduces foot velocity, gives smaller foot shear force at the heel/ground interface, and keeps the body
center of gravity between the feet. Leaning forward helps keep the center of gravity between the feet and,
if you fall, it will be forward instead of backward. Sun et al. (1996) report that, when walking down a
ramp, people over age 35 decrease stride length and steps/min.

Reduce the Consequences of the Fall

The solution depends upon the task and environment. For example, for workers on a scaffold or roof,
use a full-body harness attached to an anchorage point. Another choice is safety nets.
A fall down some stairs is comparable to falling into a hole with jagged rocks at the bottom. For falls
on stairs or on the same level, carpet can reduce peak body deceleration on the hip by 20% over hard
floors (Makie and Fernie, 1990). (Of course, in addition, carpets have high coefficients of friction and
thus have very few slips.) Stair landings reduce the distance of a fall. To minimize impact injuries, stairs,
handrails, and balustrading should be free from hostile elements such as projecting elements, sharp
edges, and corners.
Box 1 discusses hard surface floors.

Box 1
Hard Surface Floors
Concrete floors can either be: (1) the wearing surface itself or (2) a base for other materials (e.g.,
terrazzo, plastic tiles or sheeting, or carpet).
If concrete is the wearing surface, it must be durable, have satisfactory slip resistance, and be
easily cleaned.
Concrete typically is poured in slabs with joints. There are two types of joints: (1) contraction
joints (5 to 10 mm wide) and (2) expansion (isolation) joints (about 20 mm wide, filled with
compressible material). The expansion joints are not very necessary in a temperature-controlled
building and are potential trip hazards as the slab shifts. Good design is to minimize contraction
joints in a building. In addition, a horizontal reinforcing dowel between slabs will reduce slab
tilting and thus trip hazards.
If tile or plastic is placed on concrete, the problem tends to be slips rather than trips.
If liquids are used or stored in an area, there will be spills. Install drains and slope the floor
appropriately.

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Occupational Ergonomics: Engineering and Administrative Controls

9.4 Fatigue/Comfort
The discussion is divided into walking and standing.

Walking
The primary problem is the shock of heel strike being transmitted up the foot, leg and back. For shoe
solutions, see Box 2.
The energy cost of walking depends upon the terrain, with a hard surface giving the minimum cost
(Pandolf et al., 1976):
(9.2)
where
WLKMET = Walking metabolism, W/kg of body weight
C = Terrain coefficient
= 1.0 for treadmill, blacktop road
= 1.1 for dirt road
= 1.2 for light brush
= 1.3 for hard-packed snow; C = 1.3 + .082 (foot depression, cm)
= .5 for heavy brush
= 1.8 for swamp
= 2.1 for sand
v = velocity, m/s (for v > .7 m/s (2.5 km/h))

Box 2
Shoes
Athletic shoes are divided into running shoes (designed for forward movement) and court shoes
(designed for quick side to side movement).
For running, the main problem is the shock of foot strike, yielding arthritis of the knee and
hip, Achilles tendonitis, low back pain, and shin splints. Overpronation gives knee pain.
For walking, heel strike is less forceful (1.5body weight) so cushioning is less critical (but still
desirable); flexibility in the sole allows the normal heel-to-toe roll. For walking, deceleration
properties of the cushioning material is important; for standing, time is not as critical and material
stiffness and maximum compression is relevant to comfort (Goonetilleke and Himmelsbach, 1992).
At a given walking speed, the energy expenditure values increase by .7 to 1.0% per additional
100 g shoe weight; this increase in energy consumption is approximately 5 times higher than the
same weight on the upper body (Smolander et al., 1989). Legg and Mahanty (1986) found it took
6.4 times as much energy to carry a kilogram on the feet as on the back.
Feet often swell so, for fit, buy shoes when your feet are swollen (late in the day). In addition,
your left and right foot might vary slightly. Thus buy shoes with at least four pairs of eyelets as
they increase the adjustment possibilities.
People with low arches (footprint has a broad connection of two areas) will be more comfortable
with shoes with a straighter inner line (difficult to distinguish left from right shoe).
Boots support the ankle and calf as well as increasing insulation; they are especially useful for
side support, such as when walking outdoors. Boots also protect against chemicals and animal
products (such as fats and oils); some boot materials have a better life than others.
For impact protection, use a steel-toe shoe; in some industries (such as mining), metatarsal
guards are also used.

Ergonomics of the Foot

9-11

Standing
Problems can occur with floor temperature and static electricity. However, the primary problem is lack
of circulation in the leg and static loading of the muscles.
When wearing normal shoes, 23 C is optimal comfort for floors for standing and walking people;
use 25 C for sedentary people (ASHRAE, 1993). Heavy carpet will save about 1% of the total energy
used to heat the building (Hager, 1977).
Static electricity is a problem in industries such as electronics. Some solutions are: (1) raise humidity
in the air above 40%, (2) use conductive carpets (e.g., with carbon fibers), (3) use an antistatic floor
mat, (4) connect the operator to ground with a static-bleed wrist strap, (5) use shoes with static-dissipating
soles.
Teitelman et al. (1990) reported preterm births occurred more often (7.7%) when women had jobs
with prolonged standing; the rate for sedentary jobs was 4.2% and for active jobs was 2.8%.
Avoid static standing by sitting, by walking, and by shifting posture while standing. If static standing
is required, consider a cushioned floor or a footrest (Whistance et al., 1995).

Sitting
Perhaps the person can sit instead of stand. Sitting does tend to restrict movement of the shoulders and
thus reach distance. A compromise is a sit-stand seat, such as that used by post office workers sorting
mail into boxes. Nijboer and Dul (1987) reported a sit-stand seat was beneficial for upholstery workers
even though they could use the seat for only part of the work cycle. Another technique for supporting
part of the body weight is to have something to lean ontypically a counter. Another possibility is to sit
part of the time. For example, service personnel often are required by management to stand when
serving customers; they should be provided chairs for times when there are no customers. Seats should
be available for factory personnel during breaks. One firm used swing-down benches on the wall of an
aisle; during work they were up against the wall but during worker breaks they were pivoted into sitting
position.

Walking
As mentioned earlier, blood circulation in the foot can be brought to normal in as few as ten steps. Thus
design the job so there is occasional walking (such as to get supplies, dispose of materials).

Shifting Posture
It also is possible to shift the posture while standingremember the bar rail. Bar rails are designed to
improve the comfort of those standing at the bar. Satzler et al. (1993) studied four conditions: (1)
standing with one foot on a 100 mm high, flat platform, (2) standing with one foot on a 100 mm 15
angled platform, (3) standing with one foot on a 100 mm high, 50 mm diameter bar, and (4) standing
with both feet flat on a concrete floor. The three standing aids were preferred over no aid; the two
platforms were better than the bar. Note that bar patrons not only support their feet on bar rails but lean
on the bar.

Cushioned Floor
The entire floor can be cushioned (carpeted) or the floor can be cushioned locally with a mat. Mats can
also be used to raise the feet off the floor (raise above liquid) and act as a frictional surface (avoid slips).
Brantigham et al. (1970) studied a varied terrain floor mat with nonuniform resilience density;
each placement of the foot caused a slight change in horizontal angle of the foot during weight-bearing.
The concept is that many foot problems are due to the over flat nature of the built environment. The
varied terrain mat enhanced circulation in the lower extremities (reduced venous pressure) and increased
skin temperature of the calf .3 to 1.0 C (improved circulation to the surface); about 2/3 of the subjects
reported they were less tired when using the special mat.
Additional studies have been done on floor mats (Kuorinka et al., 1978; Rys and Konz, 1988; Redfern
and Chaffin, 1988; Rys and Konz, 1989; Rys and Konz, 1990; Konz et al., 1990; Zhang et al., 1990;
Stuart-Buttle et al., 1993; Redfern, 1995). Summarizing:

9-12

Occupational Ergonomics: Engineering and Administrative Controls

Floor mats improve comfort (over hard-surfaced floors). Comfort may be increased in the back as
well as the legs.
Mats should compress but not too much. Optimum is about 6% under the feet of a 70 kg adult.
Mats should have beveled edges to reduce tripping and falling.
Mats should have a nonslip surface; drain holes may be useful to aid drainage of fluids. In addition,
the mat should not slip on the floor.
Mats may have to be cleaned periodically (e.g., in food service environments). In these cases, large
mats are difficult to handle.
If a raised work platform is used to stand on, the surface should be resilient rather than rigid (i.e.,
wood or plastic, not steel). The platform also should have a high ratio of surface to holes (i.e., you
are not standing on knives).

9.5 Foot Controls

Although most controls are operated by the hands, some controls are operated by the foot. The foot
does not have the dexterity of the hand, but it is connected to the leg instead of the arm so it can exert
more force. A leg has approximately 3 times the strength of an arm. A foot control also reduces use of
the hand/arm.
Foot controls can be divided into pedals and switches.

Pedals
Pedals can be used for power and control. Power generation can be continuous (bicycle) or discrete
(nonpowered automobile brake pedal). For information on continuous power, see Whitt and Wilson
(1982) and Brooks et al. (1986).
Discrete power generally is applied by one leg; there does not seem to be any advantage to using the
left or right leg. Force using both feet is about 10% higher than using just one foot (Van Buseck, 1965).
A control example is an auto accelerator pedal.

Switches
A foot switch can actuate a machine (such as a punch press). Generally the foot remains on the switch so
the time and effort of moving the foot/leg is not important.
On-off controls (such as faucets, clamping fixtures) can be actuated by lateral motion of the knee as
well as vertical motion of the foot. The knee should not have to move more than 75 to 100 mm; force
requirements should be light. Hospitals use knee switches to actuate faucets to improve germ control on
the hands.
Avoid foot pedals/switches which must be operated while standing, because they tend to distort
posture and cause back problems.

Defining Terms
Calcaneus: The heel bone; see Figure 9.1.
Edema: Swelling of legs due to fluid retention.
Eversion: External rotation of the foot.
Inversion: Inward rotation of the foot.
Metatarsals: Bones in the foot; see Figure 9.1.
Mortise and tenon joint: A type of joint; see Figure 9.1.
Lateral: The outside (side farthest from the centerline).
Leg length discrepancy: Differences in leg length (in the same person).
Medial: The inside (side closest to the centerline).
Phalanges: Bones in the foot; see Figure 9.1.
Pronation: Rolling inward (toward the centerline) of the foot.

Ergonomics of the Foot

9-13

Supination: Rolling outward (away from centerline) of the foot.

Three-contact-rule: Rule used on ladders and steps. At least three limbs should be in contact with steps
or handles at all times.
Venous pooling: Pooling of blood in the veins of the legs.

References
Alexander, R. 1984. Stride length and speed for adults, children and fossil hominids. American J. of
Physical Anthropology, 63:2327.
Alexsson, P. and Carter, N. 1995. Measures to prevent portable ladder accidents in the construction
industry. Ergonomics, 38 (2): 250259.
Andersson, R. and Lagerloff, E. 1983. Accident data in the new Swedish information system on
occupational injuries. Ergonomics, 26 (1): 3342.
ASHRAE, 1993. Handbook of Fundamentals, ed., Parsons, R. Am. Society of Heating, Refrigeration
and Air Conditioning Engineers, Atlanta, GA.
Boulton, A., Franks, C., Betts, R., Duckworth, T., and Ward, J. 1984. Reduction of abnormal foot
pressures in diabetic neuropathy using a new polymer insole material. Diabetes Care, 7(1): 4246.
Jan-Feb.
Brantigham, R., Beekman, B., Moss, C., and Gordon, R. 1970. Enhanced venous pump activity as a
result of standing on a varied terrain floor surface. J. of Occupational Medicine, 12(5): 164169.
Brooks, A., Abbott, A., and Wilson, D. 1986. Human-powered watercraft. Scientific American, 256
(12):120130, December.
Chaffin, D., Woldstad, J., and Trujillo, A. 1992. Floor/shoe slip resistance measurement. American
Industrial Hygiene Association J., 53 (5): 283289.
Clauser, C., McConnville, J., and Young, J. 1969. Weight, Volume and Center of Mass of the Human
Body, AMRL-TR-70, Aerospace Medical Research Laboratory, Dayton, OH.
Contreras, R., Rys, M., and Konz, S. 1993. Leg length discrepancy, in The Ergonomics of Manual
Work, eds. W. Marras, W. Karwowski, and L. Pacholski, 199202, Taylor & Francis, London.
Davis, P. 1983. Human factors contributing to slips, trips and falls. Ergonomics, 26 (1): 5159.
Eisma, T. 1990. Rules changes, worker training help simplify fall prevention. Occupational Health and
Safety, 5255, March.
Gabell, A., Simons, M., and Nayak, U. 1985. Falls in the healthy elderly: predisposing causes. Ergonomics,
28 (7): 965975.
Goonetilleke, R. and Himmelsbach, J. 1992. Shoe cushioning and related material properties. Proceedings
of the Human Factors Society, 519522.
Grondqvist, R. and Hirvonen, M. 1995. Slipperiness of footwear and mechanisms of walking friction
on icy surfaces. Int. J. of Industrial Ergonomics, 16:191200.
Hager, N. 1977. Energy conservation and floor covering materials. ASHRAE Journal, 3439, September.
Konz, S., Bandla, V., Rys, M., and Sambasivan, J. 1990. Standing on concrete vs. floor mats, in Advances
in Industrial Ergonomics and Safety II, 526529, ed., B. Das, Taylor & Francis, London.
Konz, S. 1994. Change-in-level. Facility Design: Manufacturing Engineering, 118122, Publishing
Horizons, Scottsdale, AZ.
Konz, S. 1995. Work Design: Industrial Ergonomics, Publishing Horizons, Scottsdale, AZ.
Kourinka, I., Haakanen, S., Nieminen, K., and Saari, J. 1978. Comparison of floor surfaces for standing
work. Biomechanics VI-B; International Series on Biomechanics, Proceedings of 6th Int. Congress
on Biomechanics, 207211, University Park Press, Baltimore, MD.
Leamon, T. 1992. The reduction of slip and fall injuries: Part 1Guidelines for the practitioner and
Part IIThe scientific basis (knowledge base) for the guide. Int. J. of Industrial Ergonomics, 10:23
34.
Leclercq, S., Tisserand, M., and Saulnier, H. 1994. Assessment of the slip-resistance of floors in the

9-14

Occupational Ergonomics: Engineering and Administrative Controls

laboratory and in the field: Two complementary methods for two applications. Int. J. of Industrial
Ergonomics, 13:297305.
Leclercq, S., Tisserand, M., and Saulnier, H. 1995. Assessment of slipping resistance of footwear and
floor surfaces. Ergonomics, 38 (2): 209219.
Legg, S. and Mahanty, A. 1986. Energy cost of backpacking in heavy boots. Ergonomics, 29(3): 433
438.
Manning, D., Ayers, I., Jones, C., Bruce, M., and Cohen, K. 1988. The incidence of underfoot accidents
during 1985 in a working population of 10,000 Merseyside people. J. of Occupied Accidents, 10:
121130.
Maki, B. and Fernie, G. 1990. Impact attenuation of floor coverings in simulated falling accidents.
Applied Ergonomics, 21(2): 107114.
NFPA, NFPA Life Safety Code 1991, NFPA, 1 Batterymarch Park, Quincy, MA 02269.
Nijboer, I. and Dul, J. 1987. Introduction of standing aids in the furniture industry, in Musculoskeletal
Disorders at Work, ed. P. Buckle, 227233, Taylor & Francis, London.
Nodeland, H., Ingemansen, R., Reed, R., and Aukland, K. 1983. A telemetric technique for studies of
venous pressure in the human leg during different positions and activities. Clinical Physiology, 3:
573576.
Oleson, B. and Fanger, P. 1973. The skin temperature distribution for resting man in comfort. Archives
des Sciences Physiologigues, 27(4): A38593.
Pandolf, K., Haisman, M., and Goldman, R. 1976. Metabolic energy expenditure and terrain coefficients
for walking on snow. Ergonomics, 19:683690.
Pauls, J. 1985. Review of stair safety research with an emphasis on Canadian studies. Ergonomics,
28(7): 9991010.
Pollack, A. and Wood, E. 1949. Venous pressure in the saphenous vein at the ankle in man during
exercise and changes in posture. J. Applied Physiology, 1:649662, March.
Redfern, M. and Chaffin, D. 1988. The effects of floor types on standing tolerance in industry, in Trends
in Ergonomics/Human Factors V, ed., F. Aghazadeh, 401405, Elsevier, Amsterdam.
Redfern, M. 1995. Influence of flooring on standing fatigue. Human Factors, 37 (3): 570581.
Redfern, M. and Rhoades, T. 1996. Fall prevention in industry using slip resistance testing, in Occupational
Ergonomics, Eds., Bhattacharya, A. and McGloughlin, J., 463476, Marcel Dekker, New York.
Rowe, M. 1985. Orthopaedic Problems at Work, Perinton Press, Fairport, NY.
Rys, M. and Konz, S. 1988. Standing work: carpet vs. concrete, Proceedings of the Human Factors
Society, 522526.
Rys, M. and Konz, S. 1989. An evaluation of floor surfaces, Proceedings of the Human Factors Society,
517520.
Rys, M. and Konz, S. 1990. Floor mats. Proceedings of the Human Factors Society, 575579.
Rys, M. and Konz, S. 1994. Standing. Ergonomics, 37(4): 677687.
Satzler, C., Satzler, L., and Konz, S. 1993. Standing aids. Proceedings of the Ayoub Symposium, 2931,
Texas Tech. University, Lubbock, TX.
Scanton, P. and McMaster, J. 1976. Momentary distribution of forces under the foot. J. Biomechanics,
9:4548.
Smolander, J., Louhevarra, V., and Hakola, T. 1989. Cardiorespiratory strain during walking in snow
with boots of different weights. Ergonomics, 32(1): 313.
Stuart-Buttle, C., Marras, W., and Kim, J. 1993. The influence of anti-fatigue mats on back and leg
fatigue. Proceedings of the Human Factors and Ergonomics Society, 769773.
Sun, J., Walters, W., Svensson, N., and Lloyd, D. 1996. The influence of surface slope on human gait
characteristics: a study of urban pedestrians walking on an inclined surface. Ergonomics, 39(4):
677692.
Templer, J. 1992. The Staircase: Studies of Hazards, Falls, and Safer Design, MIT Press, Cambridge, MA.
Teitelman, A., Welch, L., Hellenbrand, K., and Bracken, M. 1990. Effect of maternal work activity on
preterm birth and low birth weight. Am. J. Epidemiology, 131:104113.

Ergonomics of the Foot

9-15

Van Buseck, C. 1965. Excerpts from maximal brake pedal forces produced by male and female drivers.
Research Report EM-18, Warren, MI: GM, Jan.
Whistance, R., Adams, L., van Geems, B., and Bridger, R., 1995. Postural adaptations to workbench
modifications in standing workers. Ergonomics, 38(12): 24852503.
Whitt, F. and Wilson, D. 1982. Bicycling Science, MIT Press, Cambridge MA.
Winkel, J. and Jorgensen, K. 1986. Evaluation of foot swelling and lower-limb temperature in relation
to leg activity during long-term seated office work. Ergonomics, 29(2): 313328.
Zhang, L., Drury, C., and Woollet, S. 1991. Constrained standing: evaluating the foot/floor interface.
Ergonomics, 34:175192.

For Further Information

Konz, S. 1995. Work Design: Industrial Ergonomics, 4th edition, Holcomb Hathaway, Scottsdale AZ.
This popular textbook concisely summarizes many aspects of job design and gives detailed design
guidelines.
Konz, S. 1994. Facility Design: Manufacturing Engineering, 2nd edition, Holcomb Hathaway, Scottsdale,
AZ. Gives many details and design recommendations for design and arrangement of industrial
facilities.
Ergonomics. This journal, published in England, publishes articles on ergonomics from authors around
the world.

Section II
Low Back Disorders

10
Epidemiology of Back
Pain in Industry
10.1
10.2
10.3
10.4

10.5

Gunnar [Link]
Rush-Presbyterian-St. Lukes
Medical Center

Introduction
The Magnitude of the Problem
National Studies
United States United Kingdom Sweden Canada
Cross-Sectional Studies
United States Scandinavia Israel The
Netherlands Belgium Hospitalizations and
Operations Chronic Back Pain
Occupational Risk Factors
Heavy Physical Work Static Work Postures Frequent
Bending and Twisting Lifting, Pushing, and
Pulling Repetitive Work Vibrations Psychological
and Psychosocial Work Factors

101
101
102
103

1010

10.1 Introduction
Epidemiologic research in low back pain (LBP) has been, and still is, hampered by methodologic problems
in definition, classification, and diagnosis. Objective evidence of existing low back pain is often lacking,
and peoples recall of previous episodes is poor. The intermittent nature of low back pain complicates
prevalence studies, and studies of disability due to LBP are influenced by legal and socioeconomic
factors. Methodologic problems also exist in the quantification of physical exposures that might be of
etiologic importance.
In general, data about back pain may be obtained from official health registers or by retrospective,
prospective, or cross-sectional surveys of general populations or of specific industrial populations. Such
data are useful in defining the magnitude of the problem. Care must be taken when interpreting these
data, however. As mentioned above there is no consensus on classification and diagnosis, making it
difficult to rely on insurance and hospital data (Wood and Badley, 1987). Sickness absence and disability
data are heavily influenced by work conditions and the legal and socioeconomic situation, and there is
a poor correlation between tissue injury and disability.
Data from workers compensation claims are affected by several inherent biases (Abenhaim and
Suissa, 1987): (a) all workers are not covered by worker compensation programs; (b) the claims data are
mainly administrative and therefore, while accurate on absence and cost, lack validity on symptoms and
diagnosis; (c) all workers with back pain do not file a claim, and many do not stay away from work.

10.2 The Magnitude of the Problem

The magnitude of any health problem is measured by prevalence and incidence. In a prevalence study,
the presence of LBP and other important variables is determined at one point in time (point prevalence)

0-8493-1800-9/03/$0.00+$1.50
2003 by CRC Press LLC

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Occupational Ergonomics: Engineering and Administrative Controls

or during one period of time (period prevalence) for each member of the population studied or for a
representative sample. Incidence may be defined as the number of people who develop LBP over a
specified time period, such as their lifetimes (lifetime incidence, which is synonymous with lifetime
prevalence) or in a single year (annual incidence). In short, prevalence means all cases of LBP, whereas
incidence means all new cases of LBP.

10.3 National Studies

Information obtained from different countries is considered separately because the differing socioeconomic
factors of these populations may influence the results. This is particularly true for disability data, which
are significantly determined by local legal, social, and economic factors.

United States
Between 10 and 17% of adults in the U.S. have a back pain episode in a given year (Cunningham and
Kelsey, 1984; Deyo and Tsui-Wu, 1987; Praemer et al. 1992). In about one-third of these the pain is
severe and chronic. In a large National Health Survey performed from 1985 through 1988, about 4.1
million persons per year reported a disc disorder, and another 4.6 million a back strain (Praemer,
1992). Other epidemiologic data show that back pain is the most frequent cause of activity limitation in
people below age 45, the second most common reason for patient visits (over 14% of new visits are for
back pain), the fifth ranking reason for hospitalization, and the third most common reason for surgical
procedures (Praemer et al., 1992; Taylor et al., 1994; Hart et al., 1995; Andersson, 1997). About 2% of
the U.S. workforce (500,000 workers), report compensation back injuries each year (National Safety
Council, 1991). The frequency of surgical procedures for back related conditions has risen dramatically
in the U.S. over the past two decades. In fact, it has more than doubled from 1979 to 1990. In that later
year, 279,000 back operations were performed on adults; 232,500 without fusion and 46,500 fusions
(Taylor et al., 1994).

United Kingdom
British surveys place low back pain at the top of the list of medical conditions as well. In 199293 there
were 81 million certified back-related sick days, and about 7 million visits to general practitioners for
back pain (National Back Pain Association, 1994). During the same period there were 33,000 workrelated back injuries. Frank (1993) reported that back pain was the single largest cause of sick leave in
198889, responsible for 12.5% of all sickness absence days.

Sweden
Swedish national insurance data show a consistent sickness absence in percent of all annual sickness
absence from the early sixties to the late eighties. In the 1961 to 1971 period, the average absence was
12.5% or 1% of all workdays (Helander, 1973). In 1983 the percent was 10.9, and in 1987, 13.5%
(Nachemson, 1991). Unfortunately, the number of sickness absence days rose dramatically during that
period so that the percent of insured sick listed for back pain rose from 1% of the working population
in 1970 to 8% in 1987, the number of days per absence rose similarly from 20 to 34 days per year, and
the cost in terms of lost production increased 16-fold (Table 10.1). Retirement and disability pensions
caused by back pain rose by 6000% from 1952 to 1987.
During 1983 and 1984, a prospective Swedish study analyzed all patients who were sicklisted for
LBP in a district of Gothenburg containing 49,000 subjects from 20 to 65 years of age (Choler et al.
1985). A total of 7,526 sickness absence episodes for LBP were reported over an 18-month period.
Fifty-seven percent of patients recovered in 1 week, 90% in 6 weeks, and 95% after 12 weeks. At the
end of a year 1.2% remained work disabled. Those with sciatica were out of work for longer periods of
time than were patients who had back pain only. Recurrent pain and disability occurred in 12% over the
18-month period of observation.

Epidemiology of Back Pain in Industry

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TABLE 10.1 Estimated Sicklisting for LBP and Associated

Cost Due to Loss of Production in Sweden

4.7 million
Based on 1987 wages and social costs.
3
Assuming $1 = 6 Sw. Cr.
Adapted from Nachemson AL (1991): Back Pain. Causes,
diagnosis and treatment. The Swedish Council of Technology
Assessment in Health Care. Stockholm.
2

Canada
Lee et al. (1985) analyzed data on musculoskeletal complaints based on the 1978 to 1979 Canada
Health Survey. A prevalence of 4.4% with serious back and spine problems was calculated. The total
number of disability days exceeded 21 million, and the average sickness absence period was 21.4 days.
There was no difference in prevalence between men and women.

10.4 Cross-Sectional Studies

A cross-sectional epidemiologic study is one in which a population is studied at a single point in time, or
over a defined period, in an attempt to evaluate all members of that population. In the past decades
several cross-sectional studies have been performed. Table 10.2 presents the prevalence and lifetime
incidence of LBP, as determined by some of these studies. The prevalence rates vary from a low of 12.0%
to a high of 35.0%. Some authors report a higher prevalence in females, but others found no difference.
The lifetime incidence rates are higher and range from 48.8% to 69.9%.

United States
In 1973, Nagi, Riley, and Newby determined the prevalence rates of persistent back pain of persons
between 18 and 64 years residing in Columbus, Ohio (Nagi et al., 1973). A random sample of 1,135
subjects was studied, of whom 203 (18%) reported often being bothered with pain in the back. Of
those with back problems, 62% had had a spine radiograph; 26% had worn a back support; and 4%
had had back operations.
Frymoyer et al. (1980, 1983) performed a retrospective and cross-sectional analysis of 1,221 males
18 to 55 years of age who had enrolled in a family practice facility from 1975 to 1978. Almost 70% had
had LBP. When the data from that study were extrapolated to the 50 million working American males
in the age group 18 to 55, it was calculated that 38.5 million workdays are lost annually. Patients with
severe LBP had significantly more leg complaints, sought more medical care and treatment for LBP, and
had lost more time from work for this reason when compared to subjects with no or moderate LBP.
Sciatica-like symptoms were present in 28.9% of the males with moderate LBP and 54.5% of the males
with severe LBP. Objective reports of numbness were present in 14.0% of the males with moderate LBP
and 37.4% of those with severe LBP, while weakness was reported by 17.9% of those with moderate
LBP and 44.0% with severe LBP.

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Occupational Ergonomics: Engineering and Administrative Controls

TABLE 10.2 Prevalence and Lifetime Incidence of LBP in Difference Cross-Sectional Studies

Andersson GBJ (1997): The epidemiology of spinal disorders, in The Adult Spine: Principles and Practice, 2nd
edition, [Link], Ed. Lippincott-Raven, Philadelphia, pp. 93141.

Studies by Kelsey (1975a,b) and Kelsey and Hardy (1975) sampled 20- to 64-year-olds residing in the
New Haven (Connecticut) area who had lumbar X-rays taken over a two-year period for suspected herniated
nucleus pulposus. The researchers divided the sample into those with surgically confirmed herniated discs
and those who had probable or possible herniated discs based on clinical signs and symptoms. She was
able to define a variety of risk factors related to the diagnosis of herniated lumbar disc; including sedentary
occupations, driving of motor vehicles, chronic cough and bronchitis, lack of physical exercise, participants
in certain sports (baseball, golf, and bowling), suburban residence, and pregnancy.
Kelsey et al. (1984a,b) and Kelsey and Golden (1988) later performed another case-control study in
Connecticut from 1979 to 1981 with minor methodologic modifications. The study population was 20to 64-year-old women and men who had had X-rays and myelograms at various health centers in New
Haven and Hartford. As in the previous study, they were divided into those with surgically confirmed
disc herniations and those with probable or possible disc herniations. A control group of nonback
patients admitted for in-hospital services was matched for sex and age. A number of possible risk factors
were studied and odds ratios determined. Frequent lifting and twisting were both significant risk factors,
as were driving and smoking.
The prevalence of low back pain in elderly people (over age 65) was determined in a survey of 3,097
persons living in rural parts of Iowa (Lavsky-Shulan et al., 1985). Twenty-four percent of the women
and 18% of the men had low back pain in the year preceding the survey, and 40% had back pain at the
time of the interview. Five percent of the population had been operated on.

Scandinavia
A number of studies have been performed in the city of Gteborg, Sweden (about 450,000 inhabitants).
Four are reviewed here. Hirsch, Jonsson, and Lewin (1969) interviewed 692 women (15 to 72 years of
age), selected at random to represent the adult Swedish female population. The lifetime incidence of LBP
was 48.8% and increased with age up to 55 years, after which no further increase was noted. Horal
(1969) and Westrin (1970, 1973) studied a random sample of subjects who in 1964 had been sicklisted
for LBP by physicians in Gteborg, Sweden. They were compared to a control group matched with
respect to sex, age, and sickness benefit but not previously sicklisted for LBP. Of the total group, Horal
studied 212 pairs of probands and controls, and shortly thereafter Westrin studied 214 (78% of the

Epidemiology of Back Pain in Industry

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TABLE 10.3 Data on Prevalence and Use of Medical Services from

Two Retrospective Cross-Sectional Surveys in Gteborg, Sweden

Adapted from Svensson HO, Andersson GBJ (1983): Low back

pain in forty to forty-seven year old men: Work history and work
environment factors. Spine 8:272276. and Svensson HO, Andersson
GBJ (1989): The relationship of low-back pain, work history, work
environment, and stress: A retrospective cross-sectional study of 38to 64-year-old women. Spine 14:517522.

base material). Ninety-five percent (95%) of the probands had had LBP in the preceding 3 to 4 years,
and 52% had ongoing pain at the time of the interview. In the control group, the corresponding figures
were 49% and 27%, respectively. This means that sickness absence statistics severely underestimate the
true frequency of low back pain.
Svensson and Andersson (Andersson et al., 1983; Svensson, 1982; Svensson and Andersson, 1982,
1983; Svensson et al., 1983) studied a randomized sample of 940 40- to 47-year-old men in Gteborg,
Sweden. Seven hundred and sixteen men were interviewed, and information about the remaining 234
was obtained from the Swedish National Health Insurance Office. Thirty-three percent of all sickness
absence episodes experienced during their working life were spine related, constituting 47% of all sickness
absence days; 3.6% were totally disabled and 4% had been off work more than 3 months because of
LBP in the 3 years preceding the study. Forty percent had consulted a physician, 3.5% had been admitted
to a hospital, and 0.8% had been operated on because of their LBP (Table 10.3).
The same study design was later used to survey 1,640 38-to 64-year-old women (Svensson et al.,
1988; Svensson and Andersson, 1989). Of these, 19% had been off work because of LBP in the preceding
three-year period, 3.5% for 3 months or longer. About 2.6% of 38- to 49-year-old women had significant
work disability, whereas the corresponding percentage among 50-to 64-year-olds was 5.9.
Biering-Sorensen (1982) sampled 82% of all 30- to 60-year-old inhabitants in Glostrup, Denmark.
There were 449 men and 479 women. An extensive questionnaire regarding low back problems was
administered along with objective measurements of spine function. Twelve months after the examination
99% of the study population completed a follow-up questionnaire on LBP occurring in the intervening
period. The lifetime prevalence/incidence of LBP appears in Figure 10.1 along with the one-year period
and point prevalence data. In general, increasing age was associated with increasing episodes of LBP.
Work absence at some time was reported by 22.5% of those who had LBP, 10% had needed some job
adjustment, and 63% had changed their jobs because of back pain. Of those who had experienced LBP,
60% had consulted a physician, 25% a specialist, and 15% a chiropractor (Biering-Sorenson, 1983).
About 30% had had radiographs taken of the lumbar spine, 4.5% had been admitted to a hospital, and
1% had been operated on because of LBP.
The prevalence rate of sciatica and its impact on Finnish society was estimated by Heliovaara 1988
(see also Heliovaara et al., 1987), based on a sample of 8,000 persons representative of the Finnish
population aged 30 or over. Sciatica was present in 5.3% of men and 3.7% of women. In both genders
the prevalence rates were highest in the 45- to 64-year-old group. The prevalence of definite herniated
discs was 1.9% for men and 1.3% for women. Low back syndrome other than sciatica was present in
12.5% of men and 17% of women. Disability due to lumbar disc syndrome was estimated at 3.5% in
men, 4.5% in women.

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Occupational Ergonomics: Engineering and Administrative Controls

FIGURE 10.1 Top: Prevalence rates of low back trouble by age and sex. (Redrawn from Biering-Sorensen F
(1982): Low back trouble in a general population of 30-, 40-, 50-, and 60-year-old men and women. Study design,<