Repetitive and Postural Stress Injury is usually a diffuse tissue injury with an insidious onset. This means that symptoms occur only after a long history of gradual tissue injury and reflect pain triggers that finally cross a threshold, rather than acute onset of pain from an immediate tissue injury. It also means that the tissue injury and subsequent symptoms occur at a number of locations from the spine to the extremity. This injury was typically referred to as RSI, or repetitive stress injury in the past, but with increased understanding of the pathology, it is now apparent that postural mechanics, or ergonomics, are integral to the explanation of cause. To effectively treat what we may call RAPSI (repetitive and postural stress injury), the patient needs to choose a treating physician that understands the diffuse nature of these injuries, is familiar with referred pain patterns and impingement syndromes, and is able to communicate effectively to the patient to engage them in a proactive treatment protocol that both restores unhealthy tissue and achieves a correction in the work habits and patient therapeutic routine that will stop the cause of this gradual strain injury.

During the Clinton administration, a long study determined that repetitive postural strain injury accounted for more than 60 percent of all workplace injuries, and a law was passed requiring that when a business encounters multiple claims of such injury at a particular type of workstation, that an ergonomic evaluation and change must be undertaken. This law was removed at the beginning of the Bush administration before implementation could occur. The legislation is now in limbo, and workers continue to be injured in an insidious manner at record levels. Estimates of the cost of repetitive and postural stress worker injury hover around $130 billion in compensation, treatment and lost work, and more than 330,000 RAPSI worker’ compensation claims are made yearly. This enormous amount of loss and suffering could be dramatically reduced if a thorough program of prevention and holistic treatment was truly implemented. Many patients, frustrated with the lack of real treatment, continue to work through pain, and this, most assuredly, also reduces worker productivity.

The question of what can be done to decrease these injuries and treat these patients has a twofold answer: 1) government and business must get together to improve worker ergonomic (postural mechanics of the worker, not desk design) education and correct workstation design; and 2) the patient must take a proactive position in understanding and treating the problem of chronic strain and learn correct ergonomic postural habits. Waiting for someone else to solve your problems is never a good idea. With the help of a knowledgeable Complementary Medicine physician, the patient may be able to both restore function through treatment and gain valuable instruction, individually tailored, to correct bad workplace habits and stop the daily insidious repetitive and postural strain injury. This article, and the comprehensive approach to treatment and reeducation in my clinical practice, can effectively treat and prevent future strain and sprain injuries, not only from repetitive postural strain, but also from acute strain and sprain injury that occurs because a history of chronic strain and tissue inflammation has left you open to serious injury from accidents that should not cause injury in a healthy individual.

Understanding myofascial strain and impingement injuries caused by repetitive postural strain and/or acute trauma, and the injury to underlying joint tissues that may occur

"In repetitive and postural stress syndromes, symptoms of pain, and neurological symptoms such as numbness and tingling and burning sensation, occur only after the tissue injury has been worsening for some time. It is a mistake to assume that your injury occurs only with onset of symptoms and is completely resolved when symptoms subside. Myofascial pain and neurological/vascular impingement needs a treatment strategy that addresses not just the symptoms but the underlying tissue pathology and causes."

In repetitive and postural stress injury (RAPSI), strain on deep muscles that are constantly in use, including stabilizing muscles, occurs because these muscles are overused daily with mild constant strain, and are not rehabilitated effectively during offwork hours. In time, these muscles weaken and are held in contracture, without full muscle relaxation and release, and constant muscle firing occurs. Eventually, chronic inflammation and sustained contracture trigger nagging pain and irritation of the peripheral nerves, as well as a decrease in blood circulation to the injured tissues. This decrease in blood circulation is worse during periods of sustained repetitive use and increased stress. Sufficient blood circulation is necessary to effect repair and nourish the muscles to increase endurance and strength. Insufficient blood nourishment to the tissue is call dystrophy, and can result in unhealthy tissues at multiple sites on the limb. These problems are usually diagnosed as carpal tunnel syndrome, tendinitis, lateral or medial epicondylitis, or peripheral neuropathy. The root cause of these various pathologies is usually impingement, dystrophy, and poor inflammatory function due to myofascial strain of the muscles of the neck, back and rotator cuff of the shoulder.

Sustained contracture of the deep muscles causes impingement of both the blood circulation and nerve conduction. This results in muscle tissues that are not repaired and nourished, and that are not firing effectively. The patient does not usually notice a marked weakness, but impingement of the nerve flow and blood circulation, especially at times of prolonged work and increased stress, weaken the ability of the muscles to adequately adapt to the strain of the repetitive constant work with poor postural habits. In more severe cases, occasional short episodes of marked weakness are seen as the patient inexplicably drops a pen or other implement. The impingement and decrease in circulation to the upper limbs is called Thoracic Outlet Syndrome, and is routinely tested in orthopedics. The impingement of the nerve conduction is also tested with tests of subtle muscle weakness compared to the opposite, or normal side, and with tests of nerve conduction, either manually with Roos and Tinel's Sign elicited, or with EMG (electromyogram). Unfortunately, the EMG readings are usually unclear in cases of adaptive impingement of nerve circulation that is episodically worsened or improved. EMG tests not only may miss the episodic nerve velocity problems that are intermittent due to positional impingement, but are also nonspecific with regards to site of nerve impingement or irritation. These tests should be used as part of the diagnosis, and a full review of the various tissue sites that could create the neuropathy, by palpation and exam, and of course, during direct treatment, is necessary to clarify diagnosis and etiology of the neuropathy.

Besides impingement of blood circulation and nerve conduction, myofascial syndromes typically result from repetitive and postural strain. A syndrome is a broad set of dysfunctions, and myofascial syndromes typically involve not only localized dysfunction and symtpoms, but also systemic symptoms over time related to constant muscle firing and the stress on the nervous system. Even the autonomic system may be affected eventually, contributing to increased sinus congestion, insomnia, constipation, etc. You may explore this website for more detailed information on the myofascial pain syndrome, but let's try to understand the basics of this problem here. Myofascial syndromes involve a number of symptoms attributed primarily to the muscle and connective tissues. In repetitive and postural stress injury, various muscles suffer sustained strain from constant repetitive activity coupled with strain of the stabilizing muscles from poor postural mechanics. The chronic strain causes the muscle to continuously fire in contraction, rather than going through a contract and relax phasing. Constant neural firing prevents the muscle from recycling the chemicals intregral to the neural firing, such as calcium ions and ATP fragments, and these chemicals thus accumulate in the tissue around the innervation point of the muscle. The resulting tissue lesion hardens the tissue, decreases circulation, and stimulates a chronic inflammatory mechanism, all of which perpetuate the chronic dysfunction of constant neural firing. This self-perpetuating problem needs to be stopped with some form of myofascial release.

Myofascial release may be achieved with a variety of treatments. Rest and stretch certainly helps correct myofascial dysfunction, but with more severe problems, manual trigger point release and trigger point needling are the most direct and effective forms of therapy. Usually, a short course of 4-6 treatments will achieve a return to functionality, especially if combined with other means of myofascial release. Ice and heat, if performed properly, will effectively flush accumualations from the tissue. Repetitive rocking and mobilization of the spine at the root innervation may elicit a myofascial release response. Targeted stretch, reciprocal inhibition, focused contract and release, targeted strength exercise, and active release technique of myotendinous satellite trigger points may also help in the overall therapy. Various types of electrical stimulation, some with a modulated feedback response have also been effective. A treatment protocol that utilzes all of these techniques is guaranteed to have a greater chance of success.

What the patient must focus on to heal from muscular strain, myofascial pain syndromes, and neuropathy.

Since the elimination of federal ergonomic law in 2000, some states have tried to enact such laws on their own. Criticism of the law by Republican lawmakers included statements that federal occupational law should not supercede state law in regulating the workplace, since workers' compensation was handled within state budgets. Hawaii enacted policies in 2003 that adopted general duty regulation of workplace design and began prosecution of violations, almost all of which have been settled by mutual agreement. The single case that went to court was defeated due to the federal Occupational Safety and Health Administration (OSHA) efforts to show that workers' could not effectively prove that their workplace injury was due to repetitive and postural strain alone, or that correction of job hazards would prevent their injury. Thus, the subject of workplace injury due to repetitive and postural strain suffered a setback itself due to legislation enacted to correct the problem. The lesson learned for the worker is, once again, take a proactive approach to this problem and make sure for yourself that the problem is treated effectively and thoroughly.

Ergonomic correction, or a correction of body mechanics during performance of repetitive work routines, is essential to stop reinjury and daily strain. Ergonomics should not focus merely on workplace setup and design, and ergonomic correction should not involve and assembly line approach to workplace habits and mechanics. The term ergonomic literally means body mechanics, not desk and chair design. The patient must gain a real understanding of their individual body mechanics and needs. The therapist should teach correct body mechanics in relation to the specific tissue injuries so that the patient may fully connect the relationship to their posture and work mechanics, and the specific muscles and tissues that have been injured. To achieve this, you should find a physician that communicates well, understands the pathology, treats the specific and diffuse causes, and explains the correction of body mechanics in relation to your pathology.

The treating physician should not only be able to communicate effectively to the patient to achieve understanding of the pathology and provide effective instruction on postural mechanics correction and targeted stretch and exercise, but this physician should also be able to integrate well with other physicians and therapists if necessary. Often times, the patient will undergo physical therapy, chiropractic treatment, and will receive pain medication and corticosteroid injections to control the symptoms. In Complementary Medicine, the physician should understand the various treatments and be able to provide help and advice for the patient to reduce dependancy on pain medication and achieve better results with other physical modalities.

Diagnosis of Myofascial Pain and Impingement Syndromes

The term myofascial refers to both the muscle and a broad sheet of fascia, or connective tissue under the skin, that includes nerve, blood vessels, binding of tendon and joint capsules, ligamentous tissues and sheaths around bones. Because of this, most myofascial pain is referred, patterned and impinging. The pain syndrome is more than an acute muscle strain. It is usually a chronic syndrome, or an acute syndrome with underlying subclinical problems, that involves sensory, motor and autonomic symptoms caused by tissue lesions which are electrically active loci, or trigger points. The main trigger point of a muscle is located at the point or points of innervation, causing a constant firing at the sarcolemma instead of a contract and release. This constant neural firing weakens the muscle and eventually may cause autonomic dysfunction, or overload stress of the sympathetic and parasympathetic system. Satellite trigger points are often active, especially at the musculotendonous junction, causing enthesopathy and referred pain. Problems affecting the fascia can eventually involve infammatory pathology of the joint tissues, or arthritis.

Trigger points (TrP) involve dysfunction of motor endplates, and focal ischemia, or decreased blood flow, and are found in areas of knotted or contracted muscle fiber, especially at the point of innervation of the muscle. The constant firing, or dysfunction, that comes from chronically strained and contracted deep muscles, creates a problem with recycling the calcium and ATP that are used in muscle firing. This causes accumulation in the surrounding tissues that increases pathology, with inflammatory reactions and hardening of the local tissues. Inflammatory mediators, as well as calcium and other chemicals, stimulate sensory pain response. The pain signal is transmitted on both slow and fast nerve fibers, with chronic pain signals on slow nerve fibers affecting not only the spinal cord and cortex, but also the hypothalamus and forebrain, creating a complex pain syndrome with autonomic dysfunction. Pain is thus often non-localized, deep, aching, regional and patterned, and in chronic syndromes diverse related autonomic symptoms may arise. If impingement, or pressure on local nerves and blood vessels, occurs, symptoms of numbness and tingling, pins and needles, burning sensation that comes and goes, or other dysesthesias, as well as the sensation of episodic motor weakness and dropsy, may be seen. Related autonomic symptoms are diverse, but often complaints are made of insomnia, abnormal sweating or dryness, nasal congestion, dizziness, tinnitus, imbalance and distorted weight perception of lifted objects causing dropping of implements at work.

Myofascial syndromes are objectively diagnosed by physical exam. Surface EMG may show accelerated fatiquability, and thermography and skin-resistance point finders may identify the trigger points, but these tests are rarely performed. Simple postural, range of motion and strength exams allow the physician to accumulate data on muscle length and strength, and affects on the joint mobility, and this pattern of data, coupled with palpation of trigger points, is a simple and definite means of specific diagnosis. Trigger point palpation and needling will trigger patient symptom complainst, identifying causal muscles. Not only complaints of symptoms from trigger point stimulation, but also localized twitch responses may be noted. Sensitivity to and recreation of TrP symptoms will vary greatly between patients. Pain is usually marked when the patient suddenly contracts against resistance with the muscle in a shortened position, and this resisted isometric exam may be used at the end of exam to further clarify specific muscle pathology.

Each muscle has a pattern of symptoms and referred pain. The main trigger point, or point of innervation, is located in the center of the belly of the muscle, although some large muscles have multiple points of innervation. Tendinous insertions may be palpated for trigger points, and the muscle fibers may be palpated along the fibers horizontally to find knots or hard wiry areas that identify more satellite trigger points. The location of trigger points and the patterns of symptoms and dysfunction is outlined clearly in Dr. Janet Travell and Peter Simon's two volume Myofascial Pain and Dysfunction, The Trigger Point Manual. Videotape of Dr. Travell performing exams on key muscles is also available. This book also outlines the most suspect of muscles for all regions of the body, in a descending order of most frequent involvement in studies, at the beginning of each part in the book. It also gives frequent associated muscle pathologies and specific tests, and describes the needling approach to most trigger points. These books are thus essential to the clinician.

Another essential diagnostic text when considering musculoskeletal pathologies of the extremities is Warren Hammer's text Functional Soft Tissue Examination and Treatment. Differential diagnosis is clear in this text, and a description of active release technique (ART), usually used on the enthesopathy, or trigger points of the myotendinous junction, is clear. Of course, clinical experience is the only real way to accumulate an expertise in trigger point palpation, manual release, needling and active release techniques. Instruction is very important for efficacy in treatment.

The understanding and treatment of myofascial pain syndromes and repetitive postural stress injury is a specialized aspect of medicine. Medical schools have not typically provided detailed expertise in myofascial pathology and have been lacking in the teaching of musculoskeletal medicine, instead focusing on orthopedics related to joint pathology that is corrected with surgical intervention, or rheumatic illness that is corrected with pharmaceutical intervention. Pain management, or physiatry, has seen increased focus in recent years, but emphasis on pharmocological management of chronic pain is still emphasized. Recently, more doctors in clinical settings have noted the need for a mulidisciplinary approach and utilization of the treatment specialties available with Complementary Medicine. Utilization of a knowledgable licensed acupuncturist with expertise in this field is becoming more popular, and this trend will benefit the patient population immensely, providing the benefits of expert diagnostic and case management services coupled with the hands-on and time intensive therapeutics available in a working relationship between the M.D. and the L.Ac.

Diet and Nutrient supplements that may help the patient with myofascial tissue health

A number of nutritional supplements and herbs have been researched and proven effective for the diffuse tissue injuries seen in repetitive and postural stress syndromes. Although the evidence is still questionable as to pronounced direct effects from these supplements on every patient, certainly those with a nutritional deficiency could benefit with supplementation. Taking these supplements with foods that contain the essential nutrient increases the absorption and assimilation, and taking forms of the active metabolites may enhance the therapeutic effects. In some cases, time released encapsulation greatly enhances the percentage of the essential nutrient chemical being utilized by the body. In addition, taking of these supplements may stimulate indirect metabolic effects that could help the tissue healing and are recommended as a therapeutic adjunct if you are so inclined. Numerous governmental studies in the U.S. have found that a high percentage of commercial nutrient supplements do not contain the labeled ingredients, or the dosage of labeled ingredients, and many contain ingredients not listed, some of them synthetic medicines to enhance immediate effects. Unlike the rest of the world, the U.S. FDA has no real laws governing this type of fraudulent behavior by the industry. Many nutritional supplement medications are manufactured by pharmaceutical subsidiaries, and the pharmaceutical industry sees a potential loss of profit if these nutritional medicines are found widely effective by the public. To insure that nutritional supplements are effective in medical care, a professional source is highly recommended. Here are a list of these evidence-based supplements most proven to aid myofascial syndromes:

Vitamin B6, or the active metabolite of B6, P5P: proven effective in studies for carpal tunnel syndrome. B6 pyridoxine, or pyroxidine 5-phosphate, is involved in more bodily functions than any other single nutrient, according to the famed Drs. James and Phyllis Balch. B6 aids in enzymatic action and promotes red blood cell formation, as well as the generation of new tissue cells. It also aids the body in maintaining health sodium potassium balance and neural firing. Signs of pronounced deficiency include fatique, dry skin, irritability, impaired tissue healing and tissue inflammation. Excessive need for B6, or P5P, may occur with chronic myofascial strain syndromes. Numerous human clinical trials have noted the ability of B6 to resolve chronic peripheral pain in selected subcategories of patients. Food sources include brewers yeast, carrot juice, spinach, wheat germ, walnuts, eggs, fish, chicken, and whole grains. Vitamin B1: B1 thiamine enhances circulation, assists in blood formation, and is an antioxidant. Signs of pronounced deficiency include muscle fatique and soreness, numbness and tingling of the extremities, pain sensitivity, fatique and constipation. Thiamin is one of the essential nutrients found to be deficient in a majority of the population, and hence, has long been required as an additive to commercial foods. Food sources include brown rice, legumes, wheat germ, whole grains and egg. Excess need for thiamine, or the active metabolite benfotiamine, may occur with chronic myofascial syndromes, even when a pronounced nutritional deficiency is not evident. A combination of B1 and B2 in a time-released encapsulation is recommended. One professional source is called ATP Cofactors, and is available from Vitamin Research. Vitamin B12 sublingual and folic acid, or the active metabolite 5MTHF: B12 cyanocobalamin aids folic acid in regulating formation of red blood cells and promoting health nerve conduction. Studies indicate that a large percentage of the U.S. population is deficient in folic acid and B12. A specific chemical, intrinsic factor, is needed in the stomach to efficiently absorb B12, and deficiency is often linked to stomach lining problems, acidity, or the taking of medications to control stomach acid. Healthy bacteria in the lower intestine may also produce B12 when needed, as is common with vegetarians and vegans. Imbalance and ill health of the intestinal flora and fauna, or symbiotic microbial colonization, is another cause of B12 deficiency. When patients reduce their primary source of B12, namely meat and dairy products, there is a transition to lower intestinal bacterial production, which is a time of pronounced B12 deficiency. To insure that intake occurs it is recommended to take the vitamin directly into the blood by intramuscular injection, or by crushing a high dose of sublingual B12 pills into powder and letting it dissolve into the membranes under the tongue. A high dosage sublingual liquid form of methocobalymin is now a preferred method of supplementation. The only excellent plant source of B12 is the herb dang gui, but natural brewers yeast, eggs, dairy fats, herring, mackerel and seaweeds are also good sources. Food sources of folic acid include barley, bran, natural brewers yeast, dates, green leafy vegetables, legumes, mushrooms, whole grains and root vegetables, as well as seafish. Vitamin C: C ascorbic acid is a potent antioxidant and required component for tissue repair, adrenal function in regulating inflammation, and aids in the folic acid metabolism. Dietary sources include fresh leafy greens, berries, citrus, asparagus, avocados, beet greens used in soup stock, black currants, papayas and mangos. I recommend Astra C from Health Concerns, a combination of three gentle but effective herbs with the best variety of natural sources of Vitamin C. Calcium and magnesium aspartate: these minerals are essential to functional muscle firing and relaxation, and the carrier aspartate effectively delivers them to the muscles. I recommend the formula SPZM from Health Concerns, which contains these supplements and a few nourishing herbs. Many forms of calcium and magnesium do not deliver these essential minerals to the body in a useful form. Circulating calcium that is not carried to the bone or tissue that needs it is now recognized as a serious health problem with long term use, causing kidney stones, joint calcification and capsulitis, osteoarthritis, and many other problems potentially. Taking calcium in the right form, with the right carrier attached, and only when needed, is highly recommended. Since the body is abundantly full of calcium stores, especially in the bone, the regulation of calcium is the key to problems with calcium deficiency. The hormone Vitamin D3 is just one part of the complex physiology of calcium metabolism (see a related article on this website). Some magnesium aspartate supplements now come with calcium phosphate added, and this may supply the muscles with the phosphates needed to better cycle ADP accumulation to a functional ATP molecule. Whole grape and seed extract, or whole pomegranate extract antioxidant: OPCs or oligomeric proanthocyandidins are potent antioxidants to aid in tissue repair, and are found in high quantity in whole grape and seed extract, whole pomegranate extract and other seed sources. Clinical studies have confirmed that antioxidant therapy is effective in tissue healing, and in fact, may be one of the most important aspects of therapy. I recommend Pomegranex from Health Concerns. Proteolytic enzymes: enzymes are proteins that regulate the rate of catabolism and metabolism in the body. Proteolytic enzymes speed the clearing of irritating protein fragments in the strained and injured tissues that result when areas of poor circulation occur and muscles are held in constant contracture. Clinical studies have confirmed the efficacy of proteolytic enzymes in the treatment of soft tissue pathologies. I recommend Health Concerns' Resinal E, which combines 5 enzymes confirmed to reduce myofascial pain as well as standard pain medication if used for over 10 days, and Serramend, a more potent proteolytic enzyme, serratiopeptidase, extracted from the silkworm. Amino acids that aid tissue repair: The Olympic swimmer Dara Torres, who won a gold medal in swimming the 50 meters in the last Olympics at age 41, stated that a combination of amino acids were responsible for the rapid tissue healing that she needed to conduct intensive training at her age. A combination of L-Arginine, L-Lysine, L-Leucine, with cofactor Vitamin B6 for increased utilization is effective, but high quality of product is important.

Information Resources

Additional nutrient therapy advice can be found at The U.S. government maintains a research database website for the public that can be quickly found at If you have trouble accessing this database by clicking on this address, Google PubMed or NCBI.