The Assessment and Management
of WRULD`s
Jonathan Daniel MCSP HCPC
Occupational Health Physiotherapist
(Director)
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What will we be looking at?
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WRULD`s Vs ULD`s?
Possible causes of WRULD`s
Introducing the top 5 ULD`s
Assessment and management of WRULD`s
Case study
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ULD`s Vs WRULD`s ?
• WRULD`s : Somewhat vague term under which a
large variety of conditions and symptoms are
classed.
• Those conditions with a specific recognised
medical diagnosis (recognised clinical tests and
clear-cut associated symptoms)
• Those whose symptoms are more of a 'diffuse'
nature which lack a clear-cut diagnosis. (Tingling ,
pins needles, numbness, heaviness)
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What are ULDs?
• Conditions which affect the muscles, tendons,
ligaments, nerves or other soft tissues and joints in
the upper limbs such as the neck, shoulders, arms,
wrists, hands and fingers. (HSE 2013)
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Q: Is an upper limb injury caused outside of work
deemed a WRULD if it is affecting their
performance at work or aggravated by work?
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Possible Causes of WRULD`s
In The Workplace
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Repetitive work
Uncomfortable working postures
Sustained or excessive force
Carrying out tasks for long periods
without suitable rest breaks
• Poor working environment
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Your current processes?
• How do you currently assess and manage your
patients with WRULD`s
• What are the aims of your assessment?
• What are you hoping to use the findings from
your assessment for?
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Primary care givers
• Given the current lengths of NHS waiting lists, as
occupational health professionals in the workplace
we are often the primary care givers.
• Therefore it is vital that we give the right type of care
at the earliest possible opportunity.
• This will help to prevent common health problems
resulting in chronic disability.
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WRULD`s
• Q:
• How can OHNs/advisors differentiate between
the different types of WRULD`s?
• A:
• Subjective history and basic assessment
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History Taking is Key
• Careful questioning is vital to help diagnose
• Patients can be poor historians!
• Very often there is no one incident or
recollection of injury
• Often there is a slow progression of symptoms
• Symptoms often don`t tie in with the
pathology…….don`t get caught out!
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History Taking is Key
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Is this a WRULD as he was out on a
works do?!
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Top 5 WRULD`S
• Shoulder Impingement/ rotator cuff
pathologies
• Tennis elbow
• Carpal tunnel
• Wrist tenosynovitis
• Frozen shoulder
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Shoulder Impingement
definition
• Inflammation of the soft tissue structures around the
glenohumeral joint.
• The main structures are:
• The rotator cuff
• Subacromial bursae
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Shoulder Impingement
definition
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Symptoms of shoulder
impingement
– Pain on lifting the arm above the head
– Pain while sleeping on the affected side.
– The outer side of the shoulder may become swollen and
may at times feel warm.
– Weakness of the shoulder muscles
– Stiffness of the shoulder and lack of certain movements
• Difficulty Fastening Bra ( women!)
• Putting on coat
• Reaching for seatbelt
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What structures are
affected in
impingement?
• The rotator cuff ( Supraspinatus muscle)
• These are the 4 main muscles responsible for holding
and moving the arm in the socket:
• The Bursae
• These are sacks of fluid underneath the muscles to help
them run smoothly.
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Shoulder impingement test
Hawkins Kennedy
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Teaching self management of
shoulder impingement
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Correct the position of the shoulder
Keep the shoulder moving but do not push through pain.
Work the arm at a waist level initially.
Keep the rest of the arm and hand functioning normally.
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Management pathway for
Shoulder impingement
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Self management
Physiotherapy
? Steroid injection
Referral to orthopaedic consultant if persistent
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Tennis Elbow
Definition:
• Tennis elbow - an inflammation of several structures
of the elbow:
Muscles, tendons, bursa, periosteum, and epicondyle
(Often caused by repetitive movements involving an
extended wrist. Screw driver, tennis)
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Tennis Elbow
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Clinical Signs of Tennis Elbow
• Dull constant pain and possible heat on the
outer part of elbow
• Point of tenderness over the lateral
epicondyle on the outside of the elbow.
• Gripping with the hand/shaking hands painful.
• Activities that use the muscles that extend the
wrist (e.g. pouring movements, lifting with the
palm down) are characteristically painful.
• Morning elbow stiffness.
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Assessment of Tennis Elbow
– Question carefully history of problem
– Difficulty opening jars, shaking hands
– Possible causes?
– Palpation on outside of elbow is very tender!
– Resisted wrist extension is weak and painful
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Carpal tunnel
• Affects the median nerve, which passes through the carpal
tunnel in the wrist and controls the movement of the hand.
• The three main symptoms are: tingling , numbness, pain
• These symptoms occur in:
the thumb,
the index finger,
the middle finger,
half of the ring finger
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Carpal Tunnel
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Who gets carpal tunnel?
Women are 3x more likely than men to get carpal
tunnel syndrome.
• Certain conditions increase risk:
• Diabetes and rheumatoid arthritis
• Pregnancy
• Sprain or fracture of the wrist
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Diagnosing Carpal Tunnel
There are several tests you can do to determine
if someone has carpal tunnel syndrome.
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Phalen’s test - press the backs of your
hands together for a minute to see if this
causes numbness or tingling.
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Tapping the median nerve
causes tingling in the fingers.
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Assessing Carpal Tunnel
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Aggravating/ easing factors
Check neck movements!!!
Ask about neck stiffness
Ask about neck pain
Headaches?...tension in shoulders?
Possible diagnostics ( nerve conduction studies)
Always recommend Physiotherapy before
diagnostics
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Teaching self management of
Carpal Tunnel
• Improve your posture
• Reduce the pressure on your carpal tunnel
• Keep the hand and the arm moving normally
• Move the wrist, elbow, shoulder, hand and neck through
a full range of movement 2-3 times daily
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Wrist Tenosynovitis
• De Quervain's tenosynovitis - a painful condition
affecting the tendons on the thumb side the wrist.
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Symptoms
• Pain on the thumb side of the wrist
• Swelling
• Difficulty moving the thumb and wrist when on doing
activities that involve grasping or pinching
• A "sticking" or "stop-and-go" sensation in the thumb
when trying to move it.
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Finklestein’s test
Grasp the thumb under the fingers and
bend the wrist down
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Self Management
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Stretches
Ice
Self Massage
Move the shoulder wrist and hand through a
full range of movement 2-3 times daily
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Treatment pathway for Wrist
Tenosynovitis
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Self Management
Physiotherapy
Steroid Injection
Referral to Orthopaedic consultant.
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Frozen Shoulder
• Frozen shoulder- (adhesive capsulitis) a condition
where a shoulder becomes painful and stiff.
• It is thought to be due to scar-like tissue forming in the
shoulder capsule.
• Without treatment, symptoms usually resolve but this
may take up to 2-3 years.
• Affects 3% adults
• Women> Men
• More common over age of 50 years
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Frozen Shoulder contd
Signs/Symptoms:
• Shoulder flexion , abduction and rotation
restricted +++
• Cant get hand behind back/ or brush hair
• Will hitch their shoulder when lifting arm up
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Managing ULDs in the
Workplace
• Assess the risks – this means looking around your
workplace to see which jobs may cause harm
• Decide how likely it is that harm will occur, ie the
level of risk, and what to do about it;
• Change the way work is organised to help reduce
risk;
• Help sufferers when they come back to work.
(HSE 2013)
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What if the individual upper limb
tests are negative?
• Symptoms may be coming from higher up the chain Typically at the cervical spine.
• If you suspect a neck problem eg if individual is
complaining of pins and needles or altered sensation.
This requires early referral to physio.
• Much can be done for neck, shoulder wrist and hand
problems through the correction of posture.
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The Brachial plexus
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More diffuse symptoms
• More diffuse symptoms / non specific
symptoms will need further investigating/
assessment
• Eg: Aches, pain, tingling, cramps, numbness,
heaviness.
• Referral to a Physiotherapist is vital.
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Self management of Upper
limb disorders
• Refer to self management leaflet
• Ice when acute, heat for general muscular
tension
• ? medications
• Keep surrounding joints moving regularly
• Correct posture
• Relaxation for tension related problems
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Treatment pathway for Upper
Limb Disorders
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Self management
G.P. for medication
Physiotherapy
? Steroid Injection for problematic cases
Consultant referral if persistent ( Scans, Xray)
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Summary
• Early intervention produces the best and fastest results.
• Most effective treatment for WRULD`s lies in a combination
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hands-on techniques,
exercises,
relaxation,
good workstation ergonomics
advice on posture
work pacing
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Case Study
• 25 year old female
• Food production line worker. Long shifts, static postures
• Referred to Physiotherapy post carpal tunnel release. No
improvement in Symptoms post op
• Had bilateral tingling in wrists and fingers
• No one had examined her neck movements prior to surgery!
• Very stiff neck Particularly extension and rotation.
• Upper limb nerve tension problems++
• Treatment= mobilised neck and given neural stretches
• Symptoms improved 80% in 2 sessions. Regular mobility ex`s for
neck
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Questions Please??
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