The idea that specific patient populations require specific considerations is not new in orthopaedic surgery. Sports medicine stands as a very well-defined example of population-specific treatment. Based on their activities and specific injuries related to those activities, athletes—especially scholarship and professional athletes—are often treated differently than a more sedentary individual with the same injury might be treated.
The attention given to understanding injury mechanisms and athletes is extensive, as are the research time, money, and effort directed toward sports medicine. Unfortunately, the same cannot be said for research focused on workers who use their bodies physically in their jobs. The thought of treating an “injured worker” may make orthopaedic surgeons roll their eyes as they focus on the role of the workers’ compensation system in the patient’s care.
This is unfortunate because many workers may be injured off the job or may have chronic conditions that are not caused by, but are directly related to, performance of their job. Yet the cumbersome nature of the workers’ compensation system in many states means that these issues are not getting adequate attention. This leads to an insufficient focus on the specific issues regarding the worker.
Why a labor focus?
Although every orthopaedic surgery resident may understand the biomechanics of the pitching shoulder, few are aware of the shoulder biomechanics of a high-powered drill user. By focusing on injury mechanism and thoroughly questioning the workers regarding the specific demands of their occupations, I learned that the use of high-powered drills and screwdrivers leads to significant shoulder and elbow pathology.
Although initially counterintuitive to me, because it seemed that the use of these tools would decrease the amount of stress on the upper extremity, I later learned that these tools may catch, inducing a tremendous amount of torque into the upper extremity. According to the workers I have interviewed, including labor leaders, shoulder and elbow injuries due to this particular tool are highly prevalent.
Imagine the amount of research that can be done on this one issue. Biomechanic, epidemiologic, qualitative, and quantitative studies are warranted to further elucidate this issue. And this is just one tool used in many occupations.
It is no longer sufficient to simply lump workers into two groups—manual laborers or sedentary workers. Just as an 18-year-old female field hockey player, an NFL down lineman, or marathoners and power lifters of either sex all have very specific risks and well-defined injuries, laborers in different jobs have the same diversity of pathology and risk. Farmers, steelworkers, housekeepers, mail carriers, and other laborers deserve the same level of attention to detail and understanding of diversity as afforded to athletes of various sports and ages.
Rotator cuff, adhesive capsulitis
A good example of a treatment algorithm that insufficiently quantifies the particular risks associated with various occupations is the approach to rotator cuff tears. Although the AAOS Appropriate Use Criteria on the Management of Full-Thickness Rotator Cuff Tears is an excellent guideline, there is room for increased delineation of occupational risks.
Consider the 52-year-old drywall hanger who has a 2-cm full-thickness supraspinatus tear and is mildly symptomatic. He uses his shoulder for heavy overhead activities daily, and he expects to keep working for another 10 years. What is the appropriate treatment for him, given the specific risk factors of his job? How well does the surgeon understand these occupation-specific risk factors? How do the occupational demands alter the natural progression and risk factors associated with this injury? Is there reason to consider augmentation of the repair based on these demands? The questions around this situation are legion, and the answers for this patient may be dramatically different than those for a sedentary salesman.
Frozen shoulder is another area where the algorithm stresses conservative management for a prolonged period. Although this may be a reasonable option for an accountant, a large diesel mechanic or housekeeper may find that delaying definitive management may place their livelihood at risk.
I recently treated a mechanic with an established frozen shoulder who was on the verge of losing his job due to the condition. The insurance company insisted that he have extensive nonsurgical treatment. His employer stated that he had “a few more weeks to sort this out” and after that, this well-employed worker with a mortgage and college tuition payments was looking at a possible devastating personal and family financial collapse.
It took hours to secure authorization from the insurance company for the capsular release that provided the definitive immediate treatment this patient wanted. I found nothing from the AAOS or any other resource that would help me advocate for this patient. It came down to begging the sympathy of the reviewer. We got lucky; the patient received authorization and the necessary surgery. He returned to work with full range of motion and no pain at 3 weeks.
I have learned a tremendous amount about the medical, occupation-specific risks, and social aspects of workers by making them a priority in my practice. I have met with employers and unions, toured factories and jobsites, and spoken with occupational medicine physicians to fill the blanks in my orthopaedic education. I believe that many questions are not being asked by the orthopaedic community and, therefore, are not being answered.
A 3-prong proposal
To address this void in orthopaedics, I propose taking the following steps.
- Form a discussion group among surgeons about these issues. In my practice, we call this “Farm and Labor Medicine,” which acknowledges that this is a specific patient base and a unique group. It also avoids confusion with occupational medicine and any reference to the workers’ compensation system. My patients have been enthusiastic about the idea that surgeons would focus on health issues concerning blue collar workers.
- Use a term other than “injured worker” so as to avoid confusion with workers’ compensation system issues. In my practice, we use “laboring worker.”
- Take additional time to discuss in-depth the job requirements of laboring workers being treated. I have found my understanding of exactly what is required in a job to be based on insufficient knowledge, which my patients can remedy. I have also found that visiting a workplace is just as educational and worthwhile as attending an athletic event with respect to understanding potential injury mechanisms and the demands being placed on the musculoskeletal system.
In conclusion, I believe that a new area of focus on the “laboring worker” is warranted in orthopaedics. If the orthopaedic community spent just 10 percent of the time and effort that it focuses on the athletes on the care of laboring workers, we may realize the work necessary to advocate and care for laborers in society.
The people who grow our food, keep the lights on, keep the streets clean, and basically keep our society functioning have many diverse jobs, with different risks, demands, and injuries. The treatment of these patients must reflect those differences as well as the ethical issues surrounding care and its impact on their financial stability.
The potential for research in this area is exciting. The need for including these issues in treatment algorithms is significant. By examining our current understanding of job demands and injury mechanisms and developing a broader understanding of the injury in the full context of the laboring worker’s life, we as orthopaedic surgeons can better serve those who make our lives better on a daily basis.
Rick Goding, MD, is a clinical instructor at the University of Illinois College of Medicine and chief clinical coordinator of the Tissue Biomechanics Lab at University of Illinois College of Engineering. He can be reached at email@example.com.