Author(s): Lawrence G Chang, DO, MPH, Tracie K Dang, DO, Michael R Lem, MD, Elver S Ho, MD
Originally published: October 6, 2015 Last updated: October 30, 2025
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Disease/Disorder

Definition

Occupational musculoskeletal (MSK) disorders include a range of conditions that impair physical function and limit the ability to work. The Occupational Safety and Health Administration (OSHA) defines occupational injury as harm resulting from a work accident or single instantaneous exposure, and occupational illness as an abnormal condition resulting from environmental exposures in the workplace. Broader work-related disorders may reduce capacity to work even if not directly caused or aggravated by occupational exposures.1

Etiology

The causes of MSK disorders are multifactorial, involving both physical and psychosocial determinants. Primary risk factors include heavy physical labor, high body mass index, psychosocial demands, and smoking.2 Region-specific risks also exist: neck pain is strongly associated with poor posture; low back pain is more common among younger workers; and wrist or hand pain is linked to prolonged computer work, awkward posture, repetition, older age, and female sex.3 Cumulative trauma and nerve entrapment syndromes, such as carpal tunnel syndrome, often develop in settings with repetitive activity, limited task variety, few breaks, and increased work expectations, particularly in aging populations.3 Importantly, psychosocial stressors—including low job control, effort–reward imbalance, and unsafe workplace culture—magnify physical exposures.4-6 Occupations such as construction and law enforcement combine both physical and psychological burdens, placing workers at higher risk of injury.5

Epidemiology including risk factors and primary prevention

In 2020, the U.S. Bureau of Labor Statistics reported 2.7 million nonfatal injuries and illnesses, with approximately 43% leading to days away from work.7 MSK disorders accounted for 21% of these cases, with sprains, strains, and tears being the most frequent injuries. The median time away from work was 14 days, with the hand and knee most frequently affected. Men represented 60.9% of cases, and workers aged 45–54 lost the greatest number of days.7,8 The economic burden is substantial, with employer costs estimated at $13.4 billion annually and total societal losses ranging from $45–54 billion.8,9 High-risk occupations include operators, fabricators, laborers, and repair/production workers.10 Beyond occupational classification, social determinants of health—including age, education, insurance status, systemic racism, and mental health disparities—exert strong influence on return-to-work outcomes, disproportionately affecting Black men and migrant workers.2,6 Preventive interventions yield mixed results: mechanical lifting devices and team-based approaches reduce nursing injuries,11 while ergonomic aids in office settings provide limited protection.12 Lumbar supports alone are ineffective but may provide benefit when combined with worker education.13 Education-based ergonomic programs show variable results depending on context and reinforcement.14,15

Patho-anatomy/physiology

Repetitive trauma accounts for nearly two-thirds of new occupational MSK injuries. Many upper-extremity disorders progress through a cascade of inflammation, tissue repair, fibrosis, and eventual nerve involvement, mediated by cytokines such as interleukin-6 and prostaglandins.16 Some syndromes may arise from ischemic mechanisms even in the absence of classical inflammatory markers. Low back pain is particularly associated with cumulative lifetime mechanical loading, making it one of the most robustly documented risk factors across the life course.4

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time):

MSK disorders typically progress in stages, with pain—muscular, tendinous, or neuropathic—being the predominant symptom. Carpal tunnel syndrome offers a model of disease progression: repetitive motion leads to tenosynovitis, narrowing of the carpal tunnel, and median nerve compression, progressing to neuritis, dysesthesias, weakness, and ultimately muscle atrophy.

The Canadian Centre for Occupational Health and Safety (CCOHS) describe three stages: an early phase characterized by activity-related aching and fatigue that resolves with rest; an intermediate phase in which symptoms persist beyond activity and impair performance; and a late phase with persistent pain and weakness at rest, often disrupting activities of daily living and sleep.17

Treatment strategies include activity modification, physical therapy, therapeutic exercise, modalities, NSAIDs, and, in advanced cases, surgery. Graded return-to-work programs designed in collaboration with interprofessional teams remain central to effective management.

Specific secondary or associated conditions and complications

Low back pain, which is nonspecific in approximately 90% of cases, often reflects overlapping contributors such as obesity, disc herniation or degeneration, spinal stenosis, facet osteoarthritis, spondylolisthesis, or osteoporotic fracture.18 Psychological comorbidities are particularly significant: pre-existing depression markedly increases the risk of chronic pain and long-term disability.19 Prolonged unemployment exacerbates both physical and mental health, contributing to increased morbidity and mortality.20 Psychosocial “flags” are especially important to identify—fear-avoidance, catastrophizing, low self-efficacy, and poor workplace or supervisor support are consistently associated with delayed return to work, higher reinjury rates, and poor long-term outcomes.21,22

Essentials of Assessment

History

A detailed history of the mechanism and timing of the injury is essential to determine work-relatedness. If the chief complaint, history, and physical findings do not correlate, this may suggest symptom magnification or a non-work-related etiology. History should be compared to previous records for consistency. Prior injuries, underlying medical conditions, occupational hazards, and the nature of the job can all increase a patient’s risk for work-related injuries and should be carefully documented. In addition to a full medical, occupational, and exposure history, clinicians should also review prior claims and outcomes, as this may reveal risk factors for prolonged recovery discussed later.

Physical examination

A structured approach – inspection, palpation, range of motion (active and passive), manual muscle testing, sensation, coordination, gait, balance, reflexes, and special testing – provides a complete yet focused exam. Objective findings for neurological injury include reflex asymmetry and muscle atrophy, while range of motion, manual muscle testing, and sensation may be self-limited. Functional observations (i.e. gait, don/doff clothes, arising from chair) should match the physical examination.

Waddell signs suggest non-physiological etiology of pain but do not necessarily imply malingering. Distraction techniques can be used in patients with self-limited evaluations.

The physical exam should start with a general musculoskeletal assessment and expand to neurological testing depending on the injury mechanism.  To help direct treatment and optimize recovery, specific exam maneuvers should be used to elucidate the most likely cause of injury or pain including underlying biomechanical faults.  Clarifying questions are essential during provocative testing. For example, the FADIR test (flexion, adduction, and internal rotation) may elicit discomfort in the inguinal region (suggesting intra-articular pathology) or over the greater trochanter (suggesting greater trochanteric pain syndrome).  Without confirming the pain location, provocative tests lose diagnostic value.

Clinical functional assessment: mobility, self-care cognition/behavior/affective state

When a patient is not working, assessing activity at home can help establish the lowest appropriate level of work restrictions.  Avoiding responsibilities at home beyond expectations may indicate secondary gain or catastrophizing behavior. The Fear Avoidance Behavior Questionnaire, Neck Disability Index and Oswestry Disability Index can help identify patients at risk. In evaluating work-related injuries, it is important to distinguish between aggravation (lasting or permanent worsening of a pre-existing injury or condition) and exacerbation (temporary worsening). The patient and physician should also be aware that, under certain circumstances, employers may apportion disability from a current injury to a previous work injury if one occurred in the past.

Laboratory studies

Laboratory studies may be needed to rule out medical causes of complaints particularly in patients without nonphysiological risk factors who are not improving as expected.  If history and physical support alternative etiologies of pain – such as inflammatory arthritis or autoimmune disorders – further work-up may be warranted.

Imaging

Imaging should be considered to evaluate for any underlying pathology when a patient fails to progress appropriately. It is recommended to confirm the diagnosis with imaging when the pre-test probability is high. Importantly, patients should be counseled that abnormal findings must correlate with their symptoms before being considered causative, as abnormal findings in asymptomatic individuals are common.23

Supplemental assessment tools

Standardized self-report questionnaires are commonly utilized to assess functional limitations and health-related quality of life. Validated tools include the Fear Avoidance Beliefs Questionnaire (FABQ), Neck Disability Index (NDI), Oswestry Disability Index (ODI), and Short Form 36 (SF- 36).

FABQ is a 16-question investigation of how a patient’s fear avoidance beliefs about physical activity contribute to pain, with higher scores indicating more severe fear avoidance behaviors.

The NDI is a modification of the ODI and uses self-reporting measures for neck pain.

The ODI is the gold standard of low back functional outcome tools. ODI scores are converted into a percentile, with higher percentiles equating greater disability.

SF-36 considers physical, emotional, and social functioning, plus general health perceptions on a 0-100 scale with greater scores equating lesser disability.

Early prediction of outcomes

Several factors can help predict persistent disability after musculoskeletal injury. Many principles of chronic pain and its management also apply to return-to-work outcomes. For example, hand fractures are the most common work-related fracture, with an average of 56 days to return to full duty.24,25 While injury severity strongly influences prognosis, studies have shown other determinants of return to work after hand injuries such as post-traumatic stress disorder are associated with the injury and ongoing pain.26 Similarly, almost 30% of people with acute LBP develop chronic pain.  Chronic intractable pain is compounded by comorbidities including depression, behavioral disorders, substance abuse, prolonged disability, and secondary gain. Prolonged pain diminishes the likelihood of returning to work: return-to-work rates for LBP drop to 50% after 6 months, 25% after 1 year, and less than 5% after 2 years.27

Environmental

The work environment significantly influences an individual’s decision to return and stay at work. Job satisfaction is a stronger predictor than job activity for the likelihood of filing of a future back claim.28 Supportive organizational policies and practices – such as work accommodations and pain self-efficacy – are associated with higher return-to-work rates and better work role functioning.29 Conversely, patients with chronic pain often report that unsupportive work environments, or having their injury’s legitimacy questioned by coworkers, negatively impacted their decision to remain at work.30

Social role and social support system

Social support plays a critical role in healthcare outcomes and return-to-work rates. Patients with weaker perceived social support had lower rates of returning to work and higher rates of comorbidities including depression and anxiety. These patients were also more likely to identify as young, black, and male, which highlight the influence of social determinants on health and return-to-work outcomes.31

Within the workplace, social support from supervisors can improve return-to-work outcomes. Low levels of support are linked to higher rates of reinjury and interrupted returns.32

Governmental support can also be beneficial in helping people return to work. For example, the majority of participants in a Washington State return to work program, which involved vocational services, reported significant improvements in returning to and remaining at work, especially when services were aligned with individual occupational goals. Washington State will also treat premorbid unrelated psychiatric illnesses that might delay recovery of an allowed industrial condition.33

Professional issues

There is a balance between being a patient advocate and fulfilling insurance carrier desires for case closure. Restrictions and off-work status should be medically based. The patient may need to be removed from work if the employer fails to follow restrictions.

Rehabilitation Management and Treatments

Available or current treatment guidelines

Official Disability Guidelines (ODG) provide evidence-based recovery durations for specific diagnoses. Different durations are provided if the diagnosis is not workers’ compensation.

At different disease stages

Traditionally, protection, rest, ice, compression, and elevation (PRICE) have been employed after an acute injury.  However, others have more recently suggested a transition to PEACE & LOVE (protection, elevation, avoidance of anti-inflammatories, compression, education, load, optimism, vascularization, exercise).34

Residual impairments in strength and range of motion in the post-acute or post-surgical phase are addressed with physical or occupational therapy.

Sleep also plays a critical role in returning to work as sleep disturbances were associated with increased higher alcohol consumption, greater body mass index (BMI), lower physical activity, higher anxiety, and an increased likelihood of not returning to work.35 Studies have found that restorative sleep and decreased trouble falling asleep can help predict faster resolution of chronic widespread pain and improved overall musculoskeletal health.36

In more protracted cases, work conditioning or work hardening are used to improve work status and function.  Work conditioning addresses work endurance using strengthening and cardiovascular conditioning.  Workers advance from daily one-hour to four-hour sessions.  Work hardening addresses task-specific job deficits and the patient attends daily sessions for several hours up to a full workday. A review shows that physical conditioning has no effect on absence duration for acute back pain and a small effect at one year to reduce sick leave in workers with chronic back pain.37 Overall, when chronic pain secondary to an initial injury is obstructing return to work, there should be consideration of a referral to a comprehensive pain center with access to pain psychology among standard medical care and therapies.

Maximal medical improvement occurs when a patient has undergone the most common healing, repair and treatment pathways (i.e. chronic medical treatments and rehabilitation). At that time, the insurance carrier may request an impairment or disability rating. Over 35 states and the federal government require the use of some editions of the “AMA Guides to the Evaluation of Permanent Impairment.”38

Disability is defined by the Social Security Act as an “inability to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months.”39 It is the purpose of the physician to perform an Independent Medical Evaluation (IME) to systematically define this subjective term of disability. This evaluation includes narrative history, clinical status, results of objective exams or tests, the cause of the injury related to employment, MMI assessment, identifying diagnoses and functional impairments, severity or permanence of limitations/impairments, analysis of job tasks, and the ability to perform said tasks.

At times a work capacity evaluation (WCE) can be done by a physical or occupational therapist to provide further objective functional information. However, objective evaluations of job performance are dependent on effort. In the context of returning to work, disability is related to both work-related and medical problems. No matter the result of an IME, the patient should be counseled that determination of MMI does not imply the lack of a need for ongoing or future medical appointments or treatments as clinically warranted. This clarification emphasizes the role of the physiatrist as a crucial member of the medical team whose primary aim is to preserve and possibly improve the function and quality of life of the patient through holistic and longitudinal care.

Special consideration should be given to patients with primarily psychological or mental health related barriers to returning to work. Among individuals with concurrent mental health and musculoskeletal disorders, a benefit is obtained from combined clinical and work-related interventions compared to clinical interventions alone.40 It is difficult to identify and define disability, especially in chronic pain patients. During examinations, patients with multiple physical and psychological barriers to returning to work exhibit significant painful behavior characteristics (i.e., catastrophizing). Thus, it is important to take a holistic approach when evaluating these patients.

Coordination of care

Care should be coordinated, involving a multidisciplinary and patient-centered approach. Along with the patient and their family, team members could include the physician, therapist, employer, insurance carrier, as well as social workers and case managers as needed.

Coordination of care involves interdisciplinary collaboration. For example, return to work slips with clear restrictions should be provided to patients and insurance carriers at the end of each visit. Clinic notes should be documented promptly. Therapists should contact physicians about the state of a patient’s well-being, especially if they are in too much pain to participate.  Employers should make efforts to accommodate and support workers, which is associated with workers’ decisions to return to or remain at work in a full or modified capacity such as productive light duty work.32 Insurance carriers must act quickly to approve treatment and testing recommendations.  Social workers could connect patients with appropriate resources to minimize the impact that social determinants (food insecurity, transportation, supplemental income, etc.) might have on the patient’s health outcomes. Case managers may assist by helping to coordinate care and provide longitudinal perspective to facilitate the care teams and patients in advancing the treatment plan in alignment with the patient’s goals. Consistent feedback from all members regarding diagnosis, goals, and work status is paramount to a successful outcome.

Patient & family education

Expectations and goals should be established at the first visit.  The patient should be informed that work restrictions are written based on the diagnosis and physical findings. It is the employer’s decision whether to accommodate.  Family members with poor outcome experiences may undermine treatment.  Activity within restrictions at home and work should be encouraged.

Measurement of treatment outcomes including those that are impairment-based, activity participation-based and environmentally-based

Functional Capacity Evaluations (FCE) which are limited by pain do not measure maximal functional abilities. The validity of FCE to determine safe return to work is questionable.42 Nonphysiological factors may be more important.

A recent review suggested that patients with lower recovery expectations experienced higher rates of work disability while also supporting the use of single-item measures to predict return to work outcomes.42 These single-item measures can include surveys involving questions of work and disability status.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Research confirms that musculoskeletal disorders are multifactorial in nature, with physical, psychological, and social components. Within the clinic, it is important to make sure that each of these components are addressed through a patient-centered approach. After an acute injury, patients tend to prioritize their physical recovery over secondary factors, such as returning to work.43

If a patient’s priority shifts to returning to work, a multidisciplinary approach can be beneficial. To address the psychological contribution which may impair return to work, cognitive behavioral therapy (CBT) has resurfaced.  A recent study of workers’ compensation clients showed that re-employment was found more rapidly in the cohort undergoing CBT than those undergoing standard job search assistance.  Scores of anxiety, depression, and stress were tallied in each group, and those who underwent CBT showed statistically significant decreases in each as compared to the control group.44 Integrating cognitive behavior techniques and focusing on functional goals in therapy may minimize disability time and reduce claim costs.

Clinicians must be aware of, and able to direct patients to, supportive resources for people following musculoskeletal injury. This information should be presented in a way that is culturally competent, which is especially important in patients who identify as minority workers.45

Historically, risk factors for protracted disability have included noncompliance with treatment, poor participation in the therapy, refusing to return to work when able, weight loss or exercise noncompliance, inability to quit smoking, patient hostility, anger, disruptive behavior, catastrophizing, and fear avoidance behaviors.46 However, it is important to explore and address the social determinants that might contribute to impairment of care. Recognition of the structural factors and systemic barriers that impact a patient’s ability to return to work after a musculoskeletal injury is an essential clinical pearl.

Cutting Edge/Emerging and Unique Concepts and Practice

Motivational interviewing (MI) is a tool to help explore patients’ goals and potential barriers to care. Patients reported that MI allowed them to build rapport with their providers and address their feelings of stigmatization following injury or disability. Its application could be beneficial and support a patient-centered approach to care.47 Its impact on helping employees return to work, after a musculoskeletal injury, is currently being researched. A randomized controlled trial investigated the impact of MI on return to work outcomes; they concluded that MI was a more sustainable option 1 year post-discharge among those employed prior to injury and that MI better equipped individuals who were unemployed at the time of injury to navigate the process of work accommodations in their new role.48 Although MI is routinely used across other healthcare domains, this study provided a foundation for future research into MI interventions focused specifically on return to work outcomes.

The data on MI is still limited in its direct applicability as a treatment option. MI has undetermined efficacy in its impact on the likelihood of returning to work among patients with chronic musculoskeletal disorders.49,50 Further research is needed to determine if this practice is beneficial in helping workers return to work after a musculoskeletal injury.

Recently, vocational rehabilitation has been investigated in its use in reducing sick absence and return to work outcomes. One randomized trial was able to demonstrate that patients in a vocational rehabilitation arm experienced a higher proportion of individuals in work at 12 months and overall improved satisfaction with care. 51

Gaps in the Evidence-Based Knowledge

Few studies use only workers’ compensation cohorts.43 These studies consistently show worse outcomes when compared to similar studies excluding compensation patients.  Task-specific causation studies are limited and often used inappropriately to infer causation for unstudied tasks.

Additionally, there is a paucity of research when it comes to more tailored vocational rehabilitation therapies. The field may benefit if more standardized therapy protocols were described in further detail and tailored to the specific musculoskeletal conditions studied.

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Original Version of the Topic

Kevin Komes, MD, Brian Toedebusch, MD, Rebecca Hogg, MD. Return to work after MSK injury in the workplace: timely return and risk factors for delay. 10/06/2015

Previous Revision(s) of the Topic

Alexander M Senk, MD, Christopher Meserve, MD, Michael H Nguyen, MD, MPH. Return to work after MSK injury in the workplace: timely return and risk factors for delay. 10/26/2019

Alexander M Senk, MD, Haley Hicks, DO, Dean Wundrach, Katherine Weir, MS, Michael Nguyen, MD, MPH, Christopher Meserve, MD. Return to Work after MSK Injury in the Workplace: Factors Leading to Timely Return and Risk Factors for Delayed Return. 12/14/2022

Author Disclosure

Lawrence G Chang, DO, MPH
Nothing to Disclose

Tracie K Dang, DO
Nothing to Disclose

Michael R Lem, MD
Nothing to Disclose

Elver S Ho, MD
Nothing to Disclose