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Preventing Overuse Hand, Arm, and Shoulder Injuries in EMS

Introduction

An EMS provider’s job involves frequent lifting and moving of patients, stretchers, and many other objects. The provider is required to help patients in the act of standing, moving, and transferring on a daily basis. Nearly every provider has experienced having to strain to lift a bariatric patient or overexerting to raise a stretcher when his or her partner is helping someone else.

Lifting puts a lot of stress on an EMS provider’s body. Orthopedic specialists often see EMS workers for lifting-related injuries. In 2016, a CDC study found that over 20,000 EMS workers were seen in emergency departments and clinics across the United States for work related injuries.

Of those injuries, over 40% were related to lifting and moving and almost 25% involved an upper extremity injury.1 With repeated gripping of the stretchers and frequent lifting, the repetitive motions predestine EMS providers for overuse injuries of the hand, wrist, elbow, and shoulder.

 

Common Pathologies of the Hand, Arm, and Shoulder in EMS

The following list of injuries is provided to increase awareness of the typical arm injuries sustained in the workplace.

 

Trigger Finger

Trigger finger is a stenosing tenosynovitis (progressively restrictive disease) affecting the flexor tendons of the fingers. These tendons originate in the forearm and travel along the palmar side of the hand to the fingers.

The flexor tendons can become entrapped due to inflammation of the flexor tendon sheath or the tendon itself. Trigger finger is typically caused by overuse of the fingers and can be linked to other systemic conditions such as diabetes mellitus and rheumatoid arthritis.

The thumb is most commonly affected, followed by the ring finger. Trigger finger presents with a gradual onset of clicking when using the affected finger leading to pain at the distal palm. Eventually the finger becomes locked in a flexed position.2

Many of the daily activities in EMS can lead to trigger finger, including any stresses to the fingers from excessive weight or simply by lifting a patient.

 

De Quervain Tenosynovitis

De Quervain tenosynovitis is a condition that affects the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons of the thumb side of the wrist. This disease process is typically caused by overuse or repetitive movements of the wrist.

Through overuse, the tendons of the wrist become inflamed, causing thickening and swelling of the extensor retinaculum. This leads to increased tendon friction and therefore pain with movement.

De Quervain tenosynovitis presents with a gradual onset of stiffness and radial-sided wrist pain. Pain may increase by gripping or raising objects.3

In EMS, this condition typically results from the repetitive action of gripping and lifting the stretcher into and out of the ambulance or the act of lifting patients.

 

Lateral Epicondylitis

Lateral epicondylitis, often referred to as “tennis elbow,” is an inflammatory condition of the extensor tendons of the forearm. The most commonly affected tendon is the extensor carpi radialis brevis (ECRB).

The ECRB originates at the lateral epicondyle of the humerus and travels down the forearm to the posterior base of the third metacarpal. The ECRB extends and abducts the hand at the wrist.

Lateral epicondylitis is caused by overuse of the extensor muscles and tendons of the forearm. Through repetitive extension and forearm pronation, the ECRB can become inflamed leading to tendinosis, microtears, and even complete rupture of the tendon.

Lateral epicondylitis typically presents with a gradual onset of pain on the lateral side of the elbow on the patient’s dominant arm, but can also affect the non-dominant side. Pain often increases with wrist extension and gripping activities, causing decreased grip strength. One study found that work-related epicondylitis may be specifically linked to lifting loads greater than 20 kg [JF2] more than 10 times per day.4

A busy EMS provider will often lift a heavy stretcher on 10 calls in a shift. That is 40 repetitions of stretcher lifting if you factor in the removal of the stretcher at the scene and placement of it into the patient compartment with the patient on it; then, removal at the hospital, and final return of the stretcher into the patient compartment after the call is completed at the hospital. Manual or awkward lifting of flexible stretchers, portable stretchers, and stair chairs can also predispose the provider to this condition.

Repetitive gripping and the use of heavy rescue equipment can also lead to lateral epicondylitis.

The use of automatic lifting and loading stretchers greatly assist in reducing strain in the wrists, elbows, and shoulders.

 

Biceps Tendinitis

Biceps tendinitis is caused by inflammation of the long head of the biceps. The biceps have two muscle heads. The short head of the biceps originates at the coracoid process of the scapula and travels along the anterior of the arm rejoining the long head near the middle of the upper arm.

The long head of the biceps originates at the supraglenoid tubercle of the scapula and remains tendinous, traveling laterally to the short head until the two heads rejoin.

As the inflammatory process develops, the long head tendon becomes swollen and the sheath surrounding the tendon thickens. Continued injury or excessive load to the area can lead to tendon tear or complete rupture.

Biceps tendinitis often occurs in conjunction with injuries of the shoulder. The inflammation to the biceps tendon can be caused by overuse and repetitive overhead motion.

Biceps tendinitis presents with pain and tenderness to the anterior of the shoulder which can worsen with overhead activity.5 Seasoned EMS workers, and those involved in repetitive strain on their biceps, are typically subjected to this.

 

Shoulder Bursitis/Impingement

Shoulder impingement occurs when the bursa of the shoulder becomes inflamed, causing pain and a decreased the range of motion. The subacromial bursa reduces friction between the rotator cuff and acromion. When inflamed, the bursa swells and inhibits the movement of the shoulder and is impinged between the rotator cuff and acromion bone.

Shoulder bursitis is caused by overuse of the shoulder joint, especially movements requiring elevation of the arm to shoulder height or above.

Shoulder bursitis presents with minimal shoulder pain while the arm is hanging down at the side. Pain increases as the arm is lifted to shoulder height – 90 degrees from hanging position.

As the shoulder reaches above 90 degrees, relief of pain is often felt. The postures that cause the most pain are collectively known as the impingement zone.6

Many patients complain of pain when trying to sleep on the affected side and difficulty with activities of daily living, such as washing hair and reaching overhead.

Some causes of shoulder impingement in EMS are: improper lifting when transferring a stretcher into or out of an ambulance; excessive weight on the shoulder from a heavy patient; excessive strain on an EMS assignment; or a protracted incident that requires an abnormal amount of lifting.

 

Shoulder Strains and Tears

Shoulder strains occur when the muscles and/or tendons of the shoulder are excessively stretched or torn. The most common site of a shoulder strain occurs at the rotator cuff.

The rotator cuff is a group of muscles and tendons that surround and protect the shoulder joint and produce movement of the shoulder. The rotator cuff consists of four muscles: supraspinatus, infraspinatus, subscapularis, and teres minor.

Each of these muscles originates on the scapula and inserts around the head of the humerus. This muscle group works together to perform rotation, adduction, and abduction of the humerus.

During any of these movements, the muscles of the shoulder can be overloaded, causing stretching or tearing. As a person ages, repetitive movements or diseases processes can cause muscle breakdown or thinning, which can make stretching and tearing easier.6

In EMS, shoulder strains and tear injuries often occur in seasoned providers. These providers have degeneration of the muscles and tendons from years of repetitive movements. EMS providers often spend many hours sitting in an ambulance, which can lead a provider to develop poor posture. Poor posture may have a cumulative effect on shoulder strains and tears, leading to increased degeneration of the musculature of the rotator cuff over time. This may eventually lead to an increased incidence of shoulder strains and tears.7 Strains of the shoulder also occur when lifting large loads.[BF3] [BF4]

 

Ways to Treat These Problems

As noted, arm and hand injuries account for a significant amount of the injuries that plague EMS providers daily. Understanding the types of injuries that EMS providers face is important to prevent these injuries.

The next step in injury prevention is identifying ways to improve lifting and moving form, and how to avoid situations that cause these injuries. This involves changing the way EMS providers use their hands and arms when lifting.

 

Grip

From assessing a patient during a rapid trauma exam to providing an encouraging touch to a family member’s shoulder after a death, an EMS provider uses his or her hands for many different tasks.

An EMS provider’s hands especially take a beating when lifting and moving a patient. The hands are the point of contact between a patient and a provider and bear the entire weight of the person or object being lifted. This action puts an enormous amount of stress on a provider’s hands.

After years of lifting stretchers with stress on the same muscle groups, the musculature of the hands and wrist begins to wear down. This wear and tear often leads to the previously described conditions.

To prevent injury, attention must be focused on the provider’s grip and hand placement. Much like a powerlifter lifting a barbell, an EMS provider must use a powerful grip when lifting a large amount of weight.

When preparing to lift a patient, the provider must take a moment to assess his or her grip. When lifting a stretcher, the EMS provider should utilize the power grip. This is the most effective grip for lifting stretchers. The provider’s palms should be face up in a supinated position. The handle/end of the stretcher should be placed in the palm of the hands with the fingers wrapped completely around the handle. The stretcher handle/end should not fall to the tips of the fingers, but remain securely supported in the palms.

 

Figure 1

 

A Demonstration of Proper Hook Grip

A modification to the power grip. to ensure a more secure hold, is the hook grip. The hook grip is used in powerlifting to ensure a firm hold when lifting heavy weights and helps to prevent hand fatigue. Proper deadlift form in powerlifting is very similar to the proper lifting techniques encouraged in EMS, thus making the hook grip applicable to EMS.

The hook grip is similar to a power grip; however, when grasping the handles, the thumb is tucked around the bar and the fingers are then wrapped around the thumb (See Figure 1). This grip is most effective when using devices such as a backboard, scoop stretcher, or flexible stretchers.

This grip takes stress off the fingers and distributes the force across the hand. This grip should be considered when lifting especially large patients or when the providers hands feel fatigued.

When lifting a stretcher, a supinated grip must be used to maintain access to the stretcher controls. However, when lifting soft/flexible stretchers or when moving patients, a pronated or palm down grip is most effective. A supinated grip places additional force on the biceps when lifting. The pronated grip relieves pressure on the biceps and distributes the force of the weight being lifted more effectively across the musculature of the entire arm. Whenever possible, an EMS provider should attempt to use a pronated grip when lifting.

 

Arm Position

After ensuring a strong grip, the EMS provider must focus on arm placement. Taking this step will help to prevent injury to a provider’s entire body.

Hands should always stay shoulder width apart and the provider must be careful when lifting any object above the head.

When lifting a stretcher from the ground, the provider’s arms should be stretched out with little to no bend in the elbows, making approximately a 180-degree angle.

 

Lifting the stretcher From the ground with straight arms.

Photo Robert Devich

 

Standing with the stretcher lifted.

Photo Robert Devich

 

Placing the stretcher in the back of the ambulance.

Photo Robert Devich

 

As the stretcher is lifted from the ground, the provider’s arms should maintain as little bend at the elbow as possible, making sure not to overload the biceps. The provider should focus on distributing the force being exerted throughout the body, making sure to engage the core, legs, buttocks, and trapezius muscles.

The provider must also take time to assess the weight of the object being lifted. If the provider is unable to maintain a steady posture while lifting the object to a standing position, lifting assistance should be attained.

When placing the stretcher into the back of the ambulance, similar steps should be followed. The force should once again be distributed throughout the body. When the stretcher in placed in the ambulance, the arms should start near 180-degrees and be bent as little as possible to get the stretcher into the back of the ambulance.

Shorter providers may need to gain extra lift by bending at the elbow. These providers must be extra cautious to not overload the biceps and, if needed, lifting assistance from other providers should be obtained.

Taking time to ensure the provider’s entire body is ready and engaged for the lift takes strain off any one muscle group and distributes the strain across a greater area. This allows the provider to safely lift more weight and prevents injuries in the process.

 

Injury Prevention

While proper form is important for preventing arm injuries, most if not all, injuries can be eradicated with proper diet and exercise paired with proper form. The process of exercising conditions the muscles to be ready to take on heavier forces.

Through exercise, muscles become better at utilizing energy, decreasing muscle fatigue and becoming thicker and stronger to lift larger loads.

With a proper diet, a provider can cut down on his or her own weight while allowing the body to utilize clean energy more efficiently.

Many injuries occur when muscles are fatigued, making a diet with the proper nutritional goals extremely important.8 Some helpful resources on diet and exercise can be found at the bottom of this article.

 

Conclusion

Arm injuries in EMS are commonplace, yet often get overlooked. Part of the process of fixing the problem is to first identify what the problem truly is. EMS providers are constantly using their arms and putting stress on the associated musculature.

EMS providers cannot change the everyday reality that they will have to lift patients; however, they can change how they lift patients. Taking time to understand the common arm injuries and to learn proper lifting form can help to prevent the incidence of arms injuries in EMS.

 

 

References

1.      Injury Data (March 20, 2018) In Centers for Disease Control and Prevention. Retrieved January 15, 2019, from https://www.cdc.gov/niosh/topics/ems/data.html
2.      Shah A, Rettig M, (May 2017) Trigger Finger Location and Association of Comorbidities. In Bull Hosp Jt Dis. Retrieved January 9, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/28902605

3.      Satteson Ellen, Tannan Shruti, (November 18, 2018) De Quervain Tenosynovitis. In StatPearls. Retrieved January 12, 2019, from https://www.ncbi.nlm.nih.gov/books/NBK442005/

4.      Ahmad Z, Siddiqui N, et al., (September 1, 2013) Lateral Epicondylitis. In The Bone and Joint Journal. Retrieved January 20, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/23997125

5.      Sarmento M, (March 2015) Long Head of Biceps: From Anatomy to Treatment. In Acta Reumatol Port. Retrieved January 16, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/25351662

6.      Teixeira da Silva Rogerio, (November 16, 2015) Sports Injuries of the Upper Limbs. In Rev Bras Ortop. Retrieved January 15, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4799138/

7.      Yamamoto A, Takagishi K, et al., (March 24, 2015) The Impact of Faulty Posture of Rotator Cuff Tears With and Without Symptoms. In J Shoulder Elbow Surg. Retrieved March 13, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/25441565

8.      Kloubec, June, Harris Cristen, (April 2016) Whole Foods Nutrition for enhanced Injury Prevention and Healing. In ACSM’s Health & Fitness Journal. Retrieved January 13, 2019, from https://journals.lww.com/acsm-healthfitness/fulltext/2016/03000/WHOLE_FOODS_NUTRITION_FOR_ENHANCED_INJURY.5.aspx

 

Resources

·         Eglitis Niklavs, Corrigan Emily, et al., (October 1, 2017) Fresh Perspectives on Safer Patient Lifting and Moving. In Journal of Emergency Medical Services. Retrieved January 13, 2019, from https://www.jems.com/articles/print/volume-42/issue-10/features/fresh-perspectives-on-safer-patient-lifting-and-moving.html

·         Fass Bryan, (October 1, 2017) Reducing EMS provider lift injuries. In Journal of Emergency Medical Services. Retrieved January 13, 2019, from https://www.jems.com/content/dam/jems/PDFs/WritingforJEMS.pdf

·         Reichard Audrey, Marsh Suzanne, et al., (January 25, 2017) Occupational Injuries and Exposures Among Emergency Medical Services Workers. In Prehospital Emergency Care. Retrieved January 17, 2019, from https://nasemso.org/wp-content/uploads/PEC_EMS-injuries-and-exposures_2017.pdf

 

Helpful Diet and Exercise Resources:

Diet

o   https://engine2diet.com/

o   https:// nutritionfacts.org/

Exercise

o   https://www.jems.com/articles/print/volume-41/issue-1/features/tips-and-exercises-to-improve-your-fitness-for-ems-challenges.html

o   Many local gyms have trainers that can get you started on a plan for your lifestyle.