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Int Arch Occup Environ Health ( 1984) 53:269-278 4 lct,{l tl Ii pltllt

Springer-Verlag 1984
Occupational musculoskeletal stress and disorders
of the neck and shoulder: a review of possible pathophysiology
Mats Hagberg
National Board of Occupational Safety and Health, Medical Division,
Box 6104, S-90006 Ume A, Sweden
Summary Disorders and complaints in the neck and shoulder regions are
common among industrial workers and are often attributed to occupational
musculoskeletal stress The possible pathophysiological mechanism of occu-
pational stress on the neck and shoulders is reviewed A mechanical origin for
cervical disc degeneration and osteoarthrosis is reported for a few occu-
pational groups However, a mechanical origin for osteoarthrosis is debatable.
A work posture involving elevated arms may accelerate degeneration of
shoulder tendons through impairment of circulation due to static tension and
humeral compression against the coracoacromial arch Furthermore, work
tasks with repetitive arm movements may evoke shoulder tendinitis or tendo-
vaginitis, probably due to friction Three possible routes to neck-shoulder
muscular pain are discussed; mechanical failure, local ischemia and energy
metabolism disturbance.
Key words: Fibrositis Myofascial syndrome Occupational health Osteo-
arthritis Tendinitis
Background
Disorders of the neck and shoulders are common amongst industrial workers
l 2, 3, 7, 30, 39 l Constrained working postures and repetitive arm movements are
ergonomic factors believed to be associated with these so-called cervico-brachial
syndromes In order to improve the working environment with regards to occu-
pational musculoskeletal stress, it is essential to have some knowledge of the
pathophysiology of mechanical stress on the musculoskeletal system Informa-
tion about the relationships between exposure to physical load on the one hand
and disorders of the musculoskeletal system on the other is difficult to obtain,
because it is scattered over many specialist fields in such different areas as work
physiology, sports medicine, orthopedics, rheumatology and neurology This
presentation is an attempt to make a brief review on the injurious effects of
musculoskeletal stress with special reference to occupational disorders of the
neck and shoulder.
Degenerative joint disease
Osteoarthrosis or osteoarthritis is the most common pathological condition of
joints It is characterized by disorganization and loss of cartilage and proliferation
of tissues in and adjacent to the articular surfaces l 58 l The etiology and concept
of osteoarthrosis is an intensely controversial issue l 13, 59 l A possible mechani-
cal origin for osteoarthrosis has been suggested by some researchers le g 50, 61 l.
Radin l 50 l claims that the precipitating cause of osteoarthrosis is increased stress
on the cartilage, such as repetitive impulsive loading, possibly preceded by trabe-
cular microfractures in the subchondral cancellous bone caused by trauma.
However, many researchers dispute these theories of a mechanical origin for
osteoarthrosis, e g Huskinsson et al l 31 l who reported clinical evidence of
osteoarthrosis as a polyarticular disease, with radiological or electron micro-
scopical evidence of deposition of calcium salt They suggested that osteo-
arthrosis is due to an active metabolic abnormality of articular cartilage l 31 l.
There are no reports concerning the relationship between occupation and
osteoarthrosis in the glenohumeral joint An analysis of 83 patients with
acromioclavicular arthrosis revealed no relation to occupation l 62 l Sterno-
clavicular arthritis (including osteoarthrosis) is a common and frequently
neglected disorder, which may cause pain and limit shoulder joint motion l 63 l.
The possibility of occupational trauma to the sternoclavicular joint causing
osteoarthrosis is indicated by the recurrent sternoclavicular trauma caused by
weight lifting l 65 l.
There are only a few reports on the prevalence of degenerative changes in the
cervical spine in different occupational groups Dentists have been reported to
have more "osteochondrosis" and "spondylosis" than controls l 55 l, but the radio-
logical criteria were poorly defined in the study Lawrence l 37 l found that coal-
miners had more cervical disc degeneration than non-miners These studies do
not show conclusively that cervical disc degeneration may be accelerated by
occupational stress.
The importance of occupational stress as a factor in degenerative joint disease
is still obscure In previous studies, exposure was classified by occupation
l 37, 55, 62 l and not by work task or evaluation of the local stress on the cervical
spine and shoulders Further studies in which the occupational stress exposure is
better defined are necessary.
Insertion disorders
Insertion of tendons, ligaments and articular capsules consist of collagen fibers,
which are distributed in a fan-shaped pattern into the bone It is claimed that local
ischemia can cause disorders at the insertion site l 45 l This local ischemia can
develop as a result of the transfer of blood flow from the insertions to the working
muscles l 34 l Ischemia leads to a degeneration of the tissue in which micro-
270 M Hagberg
Occupational stress and disorders of the neck and shoulder
ruptures may produce inflammation and pain This disorder has been named
enthesopathy, "insertion disorder" Inflammation is common in the neck in liga-
ment attachment of the spinal processes and in the insertion of ligaments in the
occipital bone l 6 l There are no reports in which defined enthesopathies in the
shoulder and neck have been related to occupational strain.
Stress on tendons
A tendon consists of collagen fibers in a parallel arrangement and of a small
number of elastic fibers which provide the elasticity of the tendon Ruptures are
likely to occur at the point where strength is lowest Rathburn and Macnab l 52 l
showed that the supraspinatus tendon, the biceps brachii tendon and the upper
part of the infraspinatus tendon have a zone of avascularity They found that
microruptures and degeneration (focal cell death) were predominantly located to
this area of avascularity l 52 l Thus the nutrition and circulation of the tendons
seems to be an important factor for degenerative changes in the tendon The
degeneration together with microruptures increases the chances of a trauma
causing total or partial rotator cuff tears l 40 l Aging of the rotator cuff is strongly
associated with degenerative changes l 10 l.
Impairment of the circulation may occur if the humeral head compresses the
tendons l 6, 52 l, but it has also been shown that the venous circulation in a tendon
decreases and finally stops as the tension of the tendon increases l 54 l Hence, in
work tasks requiring the sustained elevation of arms, an acceleration of the
degeneration of the rotator cuff tendons may be the result of both the humeral
head compression of the tendon against the coraco-acromial arch and of the
sustained tension in the tendons (Fig 1).
Degenerative tendinitis is a painful disorder of the shoulder due to degenera-
tion changes aroused by exertion l 9 l This may be due to the debris of cell death,
an early degenerative tendon change l 10 l, which triggers an inflammatory
"foreign body" response l 40 l Calcific tendinitis is believed to represent a varia-
tion of degenerative tendinitis l 9 l, the calcification of the tendon is a "way
station" on the road to degeneration l 11,56 l.
Herberts and Kadefors l 28 l suggested that an ischemic effect, due to constant
tension on the supraspinatus tendon from working with elevated arms, is a pos-
sible major etiological factor in supraspinatus tendinitis They have also shown
Humeral compression of Constant tension of Ageing
tendon against the coraco tendon
acromial arch
Impaired circulation
and nutrition
Focal cell deaths
Fig 1 Factors contributing to degeneration (focal cell death) of rotator cuff tendons In work
tasks requiring elevation of the arms, humeral compression against the coracocromial arch
and static tension of the tendons may impair circulation and nutrition of the tendon causing
focal cell death in the tendon and by that accelerate degeneration
271
M Hagberg
Degenerated tendon
Temporary increase of
occupational stress %
Trauma-microruptures
Infection (viral, urinary-tract)
Rupture of chalk deposits
Tendinitis
Fig 2 Possible factors evoking degener-
ative rotator cuff tendinitis
that supraspinatus tendinitis is more frequent among welders than among office
workers, probably due to the different stress on the supraspinatus tendon during
work l 28,29,30 l Degenerative tendinitis was also common among industrial
workers with prolonged shoulder pain, where the local load on the shoulders as
the working height for the arms was significantly higher than that of matched
controls l 7 l.
Tenosynovitis is an inflammation of the tendon sheath l 36 l In the intertuber-
cular groove the tendon of the long head of the biceps and its synovial sheath may
rub on the lesser tuberosity during overhead arm movements l 6,44 l Capillary
dilatation, edema and progressive cellular infiltration of the bicipital tendon and
the synovium might be the pathophysiology of bicipital tendinitis l 56 l Since the
anatomy of the intertubercular sulcus may vary between individuals l 56 l, the
susceptibility to develop bicipital tenosynovits may also vary after exposure
to mechanical, e g , occupational stress Studies on rabbits have revealed that
tendon inflammation can be evoked by repetitive contractions l 51 l In biopsies
from rabbit tendons and from patients with tendinitis, it was found that inflam-
mation was due to edema and deposition of fibrin in the paratendon and the
muscle interstitium l 51 l In human volunteers, clinical signs of tendinitis have
been reported after experiments involving repetitive forward flexions in the
shoulder and repetitive lifting tasks l 22, 25 l Kuorinka and Koskinen l 35 l reported
a correlation between "muscle-tendon symptoms" and number of pieces handled
in a light mechanical industry Bjelle et al l 8 l found that tendinitis was located in
the right shoulder only among industrial workers who also had a higher fre-
quency of shoulder forward flexion and abduction more than 60 degrees in the
right shoulder as compared to matched controls.
Reactive or post infective arthritis is arthritis that may develop after acute
infections However, the disorder does not necessarily involve a joint, but selec-
tively localizes to extra articular structures such as tendons and muscles l 46 l.
Reactive tendinitis in the shoulder has been reported to be a common finding
among industrial workers l 8 l Thus a (viral) infection may predispose a subject
exposed to local shoulder stress to reactive tendinitis in the shoulder (Fig 2) One
could speculate whether an infection, which activates the immune system,
increases the possibility of a "foreign response" to the degenerative structures in
the tendon.
272
Occupational stress and disorders of the neck and shoulder
Stress on muscles
Muscle tenderness is perhaps the most common finding amongst industrial
workers with pain and discomfort in the neck and shoulder l 8, 41, 47 l Muscular
tenderness is reported to be common among workers exposed to repetitive arm
movements and/or static arm positions, such as shop assistants and assembly line
packers l 39 l, film-rolling workers l 48 l and assemblers l 8,47 l Confusion is
complete in the terminology of "muscular" neck and shoulder disorders The
same patient, by consulting different physicians, may get the diagnoses of tension
neck, fibrositis, fibromyalgia, myofascial syndrome, or cervico-brachial syn-
drome The terms "fibrositis" or "primary fibromyalgia" do not apply to "occupa-
tional" neck and shoulder muscular disorders since these terms require the
exclusion of secondary causes such as occupational trauma l 64 l "Myofascial
syndrome" is defined as a painful condition of muscle characterized by the
presence of one or more discrete areas, which are tender and from which pain
may radiate when pressure is applied l 20 l "Myofascial syndrome" may be a
suitable term for patients with neck and shoulder pain, where the disorder is
localized to the muscles l 24 l.
Muscle pain does not originate from the contractile muscle fibers themselves
but possibly from pain nerve fibres situated in the walls of blood vessels and in
the connective tissue of the muscle, e g muscle-fascia l 43 l Three possible patho-
physiological routes for muscle pains as a result of physical load will be discussed
here: (a) mechanical failure, (b) local ischemia, and (c) energy metabolism
disturbance.
Mechanical failure Muscle soreness is a well-known everyday phenomenon
occurring 24 to 48 h after heavy physical exertion Recently it was reported l 18 l
that ultrastructural changes were visible in muscles after heavy, eccentric leg
exercise These changes consisted mainly of ruptures of the z-discs After a
training period these ultrastructural changes could not be observed l 17 l The
interpretation of these results was that muscle soreness developed as the result of
the z-disc ruptures, and an outflow of metabolites from the muscle fibers, which
directly or through a process of edema, activated pain receptors After a training
period the mechanical properties of the muscle improved due to reorientation of
collagen A disturbance of the collagen metabolism indicated by hydroxyproline
excretion levels was reported to be correlated to delayed soreness after heavy
exercise involving eccentric contractions l 1 l In occupational situations this
model for muscular pain can probably only be applied to temporary high local
stress involving eccentric contractions on the shoulders where the worker is
unaccustomed to the work task.
Local ischemia Yet another explanation for muscle pain and tenderness is
ischemia In a muscle contraction the intramuscular pressure increases with the
contraction level and in a continuous muscular performance, isometric or
dynamic, the circulation will be impaired at levels of contraction as low as 10-20
percent of maximal voluntary contraction l 5, 15, 23 l The impaired circulation
gives rise to an accumulation of metabolites (e g lactate), which causes a drop in
p H Ultimately the p H becomes too low for the muscle enzymes to function
normally and the ATP production is inhibited and thus the contraction l 53 l.
273
Ischemia in the muscle results both in an impaired muscle function and in pain.
When the circulation returns to normal, the pain and the decreased function
recover Despite this, several investigators have presented the idea that ischemia
is a significant factor in occupational shoulder muscular disorders l 8,21,
30, 33, 47 l It has been shown though that a relative ischemia in the quadriceps
muscle by subtotal occlusion of the femoral artery in humans may cause tran-
sient morphological strain on the type II (fast-twitch) muscle fibers l 57 l More-
over, it has been suggested by Fassbender and Wegner that disturbance of local
blood-flow in a muscle due to an increase in muscular tone is the cause of
muscular rheumatism l 16 l The hypoxia caused by the reduction of blood flow
impairs the function of the mitochondria, which is followed by an accumulation
of acetyl-Co A which stimulates the proliferation of connective tissue "mes-
enchymal transformation" l 16 l Fassbender and Wegner based their hypothesis
on the findings of degenerated mitochondria and increased glycogen deposits in
biopsies from the trapezius muscles in 11 patients with muscular rheumatism.
Awad l 4 l examined ten patients with fibromyositis In four patients the disorder
was localized to the trapezius muscle He postulated that the disorder was due to
relative ischemia in the muscle caused by mechanical injury, eccentric contrac-
tion, repeated contraction or irritation of a motor axon The trauma caused extra-
vasation of blood, in turn platelets released serotonin causing a reduction of
blood flow l 4 l Edema would result from the serotonin-induced vasospasm, and
histamin, released from mast cells, would increase the fibrositic capacity of the
reticuloendothelial system causing fibrosis l 4 l.
Ischemia of the supraspinatus muscle was shown to occur during assembling
work tasks from which patients with neck/shoulder muscular disorder were
common l 8 l That work consisted of high median contraction levels but no long-
term static contractions l 8 l It is possible that work tasks with dynamic contrac-
tions above 10 to 20 percent of the maximal voluntary contraction may cause
intermittent ischemia if the contractions are frequent with no, or just a few
seconds', rest in between In such work tasks the ischemia may be a cumulative
trauma to the muscle cell, perhaps affecting both morphology and energy metab-
olism.
Energy metabolism disturbance Energy depletion and effects on the energy
metabolism in the muscle cell have both been suggested as factors in muscle pain
and tenderness l 24,38 l Defects in the muscle energy metabolism are often
associated with painful disorders of muscle l 43 l When the intramuscular
demands for energy exceed the metabolic production, the results seems to be
muscular pain The effect of energy depletion of a muscle cell may be prolonged
since replenishing of the intracellular stores of glycogen takes more than 46 h
l 49 l In laboratory studies experimental muscular pain has been induced after
repetitive shoulder flexions l 22 l These repetitive shoulder flexions probably
produced a metabolic depletion, as was indicated by a serum creatine kinase
(S-CK) increase since CK efflux is dependent on intracellular ATP l 22, 601 The
energy depletion in a muscle may be selective to e g low threshold motor units
l 21 l, which may explain why muscular pain was found among workers with low
"static" muscular load levels l 33 l.
274 M Hagberg
Occupational stress and disorders of the neck and shoulder
Henriksson et al l 27 l proposed a primary metabolic disturbance as an alterna-
tive to an overload myopathy secondary to a more or less continuous increase in
muscle tension as the cause of myofascial syndrome in 15 patients ( 13 patients
with shoulder muscular disorders) examined by means of muscle biopsy This
was put forward after they had found mitochondrial abnormalities and reduced
values for energy metabolites in the biopsies from tender trapezius muscles l 27 l.
Among 13 patients with regional muscle tension and pain, a correlation was
found between muscle tension and the plasma myoglobin in addition to an
increase of plasma myoglobin after massage as evidence of disorder localized to
the muscle fibers l 12 l.
In occupational situations involving continuous long-term static contractions
of the neck and shoulder muscles, one could speculate upon whether an energy
metabolism disturbance in the muscle cells is the cause of muscular pain Several
years of cumulative occupational trauma due to selective or local muscle fiber
fatigue/ischemia affecting muscle energy metabolism is a simple idea.
Muscle pain syndromes localized to the neck and shoulders are not a diag-
nostic entity There is a large number of patients with myalgia where it is impos-
sible to arrive at a definite diagnosis despite extensive investigations l 42 l Mills
and Edwards l 42 l suggest that a number of specific metabolic muscle disorders
remain unidentified As for the tendons, reactive disorders due to a prior infec-
tion may localize selectively to muscles l 45 l Furthermore, viral infections were
reported to reduce muscular performance for even months l 19 l Thus a (viral)
infection may further predispose a subject with local work stress on the neck and
shoulders to a muscular disorder.
Concluding remarks
There is strong support in the literature that occupational muscular stress may
cause disorders of the neck and shoulder Constrained working postures and
repetitive arm movements are potent causative factors in neck/shoulder dis-
orders It is important to note that the same symptoms and disorders that occur
during occupational situations with repetitive arm movements may also occur in
sport activities, e g for swimmers l 26 l Perhaps some of the neck/shoulder
disorders today referred to as "occupational" may tomorrow be explained as
clear-cut rheumatic or neuromuscular diseases such as reactive tendinitis and
myalgia after infection, virus-the common cold, urinary tract infections might
be common factors in shoulder/neck disorders, which are as yet poorly under-
stood l 14 l.
How much musculoskeletal stress is needed before a neck/shoulder disorder
develops? Unfortunately there is still no answer to that question Only a few
investigations have dealt with dose-effect relationships l 8, 22, 33, 35, 39 l Jonsson
l 32 l suggested preliminary threshold limit values for long-term work, where the
muscular stress is measured by electromyography The basis for these threshold
limit values was the result of muscular endurance time studies l 32 l However,
whether these limit values are appropriate still remains to be determined.
Furthermore the "dose" may be the principal difference between occupationally
275
injurious effects and exercise positive (therapeutic) practice In therapeutic
exercise, the "dose" is rarely 2000 repetitive arm elevations more than 60 degrees
in the shoulder per day or continuous static contractions of the trapezius muscles
for several hours as have been found among workers developing muscular neck/
shoulder disorders l 8, 33 l It is essential for proper preventive measures to deter-
mine possible dose-effect relationships for occupational neck/shoulder disorders
in future research.
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Received August 16 / Accepted October 18, 1983
278 M Hagberg