A Strange Case of Carpal Tunnel Syndrome: Real—or Not?
A professional ergonomist or human factors practitioner evaluates tasks and workplaces in order to fit the work to people performing it and reduce injury potentials. These professionals occasionally hear how an employer was not much help, pre-injury or post-injury, or their medical treatment and recovery was unfavorable. Such was the experience of a journeyman welder, a boilermaker, injured on the job and who shared his concerns with the author. The man wanted his story publicized so others might avoid his experience.
The mid-forties boilermaker prospered in his 20-year work history. He never suffered an upper extremity disorder. Yet, in a post-accident evaluation, he was diagnosed with carpal tunnel syndrome (aka CTS) by a General Practitioner in a small, rural midwestern community. The injury diagnosis, CTS, is commonly a longer-developing musculoskeletal disorder (MSD)*. A more acute injury was not considered at first.
*Musculoskeletal disorder (MSD) is a disorder that may appear with repeated stress or micro-trauma to muscles, nerves, tendons, ligaments, joints, cartilage, blood vessels or spinal discs. More broadly, it can also affect the bones and skin. Further, it is a condition that forms over a period of time, rather than, e.g., a sudden or acute injury like a broken ankle.
The welder had performed a routine operation in a power generating station, crouched low to the work floor. Forgetting momentarily about a low-level, horizontal steel I-beam overhead, the gentleman stood up suddenly and struck the beam bottom forcefully, hitting the top of his hard hat squarely. Post-accident, this subject cited immediate pain in his neck that nearly drove him to his knees. The blow transmitted impact shock through his spine, affecting his head, neck, back and shoulders. In the days following, the gentleman experienced severe pain. Within a week, a fast-developing numbness took over in his hands and he then reported the claim late to his employer.
The boilermaker’s post-injury visits to the MD for advice resulted in surgery within a mere three weeks of the initial visit, which surprised the injured. The doctor conducted no exclusionary CTS in-office tests and offered no PT option. Further, no examination of other potential contributing physical issues took place. The injured felt it was a rushed process.
In defense of both the Doctor and employer in this case, neither reportedly knew of the potential to engage a post-incident Workers’ Compensation claim verification for a more profound investigation of this incident. The Ergonomics Claim Verification or ECV is a specialized examination of case facts through forensics, incorporating ergonomics and human factors principles. ECV may be conducted by qualified engineers, safety professionals or ergonomists experienced in the process. The exam is relied upon by attorneys, doctors, risk managers and insurance claim representatives for clarification about Workers’ Compensation (WC) cases. Through ECV, claims can be either affirmed or denied.
ECV examination involves reviews of the job’s techniques, postures, repetitive actions, tools, procedures, job design and equipment employed, leading up to an alleged injury. The ECV can apply to products liability and general liability incidents as well as WC cases. For many claims, ECV fact gathering may be completed through observations on site, or remotely through video, utilizing established software applications.
For the case in question the injured did not realize he could request a second opinion. His doctor’s suggestion for carpal tunnel release surgery on both hands gave him pause. The injured disagreed with bilateral surgery at once and opted instead for treatment on one hand to see how effective a single release surgery might be.
Continuing without a second medical opinion, the welder experienced surgery on one hand. The worker later explained he wanted to minimize trauma of both hands being rehabilitated at once. The surgery on one hand did not relieve his symptoms. Foregoing surgery on the remaining hand was fortuitous. The tradesman decided not to have the second CTS release.
Eventually, the worker found he could consult another doctor about his injury enigma—and did so. The second surgeon, a specialist, advised no further invasive procedures. He believed the initial injury was a result of neck trauma. That neck disorder, the surgeon deduced, was an acute injury and the cause of hand numbness symptoms related to neck inflammation and cervical disc compression. This doctor believed internal damage to the worker’s neck resulted in localized nerve pressures and inflammation translating to referred hand symptoms. Such symptoms can mirror and falsely implicate CTS.
Investigation of the welder’s background and job practices through the ergonomics process revealed the man’s tools and techniques. Repetitive hand movements were part of his work; however, high-force welding actions were absent. Highly repetitive work, coupled with high forces can accelerate and increase CTS potential.
No extreme or extensive awkward postures or other untoward MSD risks were evident in post-incident, post-surgical case review. In short, the journeyman here did not display the risk factors that generally affect those at higher risk of CTS.
After the fact analyses using software were undertaken virtually as a point of interest to determine the level of physical risks that may have contributed to the welder’s alleged injury. Two different analyses, one developed by Garg, et. al.1 (respecting upper extremity risks), the other by Rodgers2 (emphasizing muscle fatigue factors), showed similar findings: the welder’s job risks were neither uncommon nor abnormally high. Neither welding job nor technique modifications were judged to be needed.
Case outcome over a period of several months involved full healing and restoration of symptom-free hands for the welder. He returned to duties during his recovery and continued improving with no restrictions. This is important, because in classic CTS cases, if a person returns to work without job modifications, then symptoms typically return after a surgical release.
Since CTS is one of the most often mis-diagnosed MSDs, it’s reasonable to enlist a second opinion to reduce injury ambiguity. This step is advisable if a doctor quickly advises surgery. Experience has shown that surgeons with successful patient outcomes favor surgery as a ‘last resort.’ Instead, those surgeons prefer conservative treatments over invasive surgery.
Depending upon the MSD case, it can be beneficial to enlist a third party to look at the person’s job and examine its forensics. ECV forensics can help reveal whether work methods, procedures, materials or risk stressors may be factors in injury development. Presence or absence of risk factors can actually help examiners or litigators match work conditions under which an injury may have developed.
Seeking professional assistance to examine evidence linked to an injury is never to second-guess the treating physician. Rather, ECV’s objective is to review whether injury symptoms match job risks. If symptoms and risks appear to be diverse, unmatched or questionable, then claims or legal should be advised to call for a second medical opinion.
Engaging a deeper case dive with ECV evaluations and experienced physicians can assist in supporting a claim, denying a claim, or assisting MDs, legal and employers in placing recovering employees into lower risk assignments.
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References
1 Garg, A., PhD, Moore, J.S.: The Strain Index: A Proposed Method to Analyze Jobs for Risk of Distal Upper Extremity Disorders. American Industrial Hygiene Journal, May, 1995.
2 Handbook of Human Factors and Ergonomics Methods. Rodgers, Suzanne H.: Chapter - Muscle Fatigue Assessment: Functional Job Analysis Technique. CRC Press, 2004.
ABOUT THE AUTHOR: Lee J. Huber, Certified Professional Ergonomist
Lee J. Huber, CPE, is an expert witness, certified as an Ergonomist. He has over 40 years of experience, serving Fortune 500 firms across the U.S. and a variety of businesses in Canada. Service includes designing risk out of jobs across a broad spectrum of industries and educating clients how to do the same.
Copyright Lee J. Huber, CPE
Disclaimer: While every effort has been made to ensure the accuracy of this publication, it is not intended to provide legal advice as individual situations will differ and should be discussed with an expert and/or lawyer.For specific technical or legal advice on the information provided and related topics, please contact the author.
