Repetitive Stress Injury (Overuse Injury)

Repetitive stress injury [RSI], or now commonly, Overused or Overload Injury is collective term used to describe physical pains caused by excessive strain on the muscles, tendons, nerves and fascia from repetitive movements. Repetitive microtrauma or repeated strain overload overtime results in structural weakening, or fatigue breakdown, of connective tissue.


In a nutshell, this is how it happens… When connective tissue is injured, it goes through a reparative process. However, in connective tissue that is repetitively stressed beyond the ability to repair itself, the inflammatory process is perpetuated. Proliferation of fibroblasts with increased collagen production and degradation of mature collagen leads to a predominance of immature collagen. This has on overall weakening effect on the tissue.

Initial signs and symptoms of inflammation such as pain, redness, swelling and limited movement may be observed. Initially, the inflammatory response from the microtrauma is subthreshold but eventually builds to the point of pain and resulting dysfunction. The type of pain may show the stage or extent of the injury. There are stages for repetitive stress injury:

  •  Phase 1 – Pain is localized and is easily relieved when rested.
  •  Phase 2 – Pain radiates out to other parts of the body. Pain appears more quickly and disappears more slowly.
  •  Phase 3 – Pain is almost always present and can limit function.

Since RSI is a progressive condition, the longer you wait for treatment, the longer the period of recovery takes.

Repetitive stress injuries can occur anywhere in the body where there are repetitive and forceful movements. It is more common in the upper body including the neck, shoulders, elbows, wrists and hands. Overuse injury can be simple muscle tensions with recurring aching pain to involvement of other soft tissues like nerves, ligaments and tendons.

The following are the more serious types of repetitive stress injuries.

Thoracic Outlet Syndrome 

thoracic outlet

Thoracic outlet syndrome [TOS] is a term used to describe symptoms of pain and discomfort in the neck, shoulders and arms which can be associated with numbness especially in the fingers. The symptoms are cause by entrapment or impingement of the nerve bundle and/or blood vessels [artery or vein] as they pass through the scalene muscles in the neck, the first rib, or the clavicle [collar bone]. For a more detailed description check out my previous blog on this topic.

Lateral Epicondylitis [Tennis elbow]

tennis elbow

Pain in the common origin wrist extensor muscles along the lateral epicondyle and radiohumeral joint on gripping activities. Activities requiring repeated wrist extension such as the backhand stroke in tennis [thus, the term “tennis elbow”], computer keyboarding, pulling weeds in the garden can stress the musculotendinous [muscle and tendon] unit and cause pain.

Carpal Tunnel Syndrome

carpal tunnel

Carpal Tunnel Syndrome is an irritation of the median nerve as it passes through the carpal tunnel. The carpal tunnel is the tight space located in the wrist formed by fibrous bands and the carpal [wrist] bones. Any condition that causes swelling or change in position of the tissues within the carpal tunnel can cause irritation of the median nerve which results in tingling and numbness in the thumb, index and middle fingers which receive innervation from the median nerve.


The best way to manage RSI is through prevention. Avoid prolonged used of your joints by talking micro breaks every 30 minutes during working hours. Take some time to loosen your neck, shoulders, elbows, wrists, and fingers by moving and stretching them. A physical therapist can teach you the right mobility and reset drills that you can do few times throughout the day while at work.

In cases where you feel any recurring pain, numbness, tingling sensation, and limited joint range of motion in the neck, shoulder, and arms, conservative physical therapy is also the ideal first line of treatment.

Remember for aching and bothersome body pains, physical therapy is your initial option. This is cost effective as many medications, injections and imaging are unnecessary.

Get PT 1st.


Thoracic Outlet Syndrome

What is Thoracic Outlet Syndrome, what causes it, how is it diagnosed, and what are the available treatments?

Thoracic outlet syndrome is a poorly understood syndrome that presents with pain, numbness, and tingling in the upper extremity. The cause has been considered to be a compression of the neurovascular bundle between the first rib, clavicle, and the scalene muscle. This neurovascular bundle consists of the subclavian artery, the vein, and the brachial plexus.

thoracic outlet

The cervical nerve roots of the brachial plexus descend from the cervical spine and merge into trunks and cords and ultimately form the peripheral nerves that goes to the upper extremities. The symptoms of the syndrome have been attributed to vascular and/or neurologic compression.


The symptoms of a person with thoracic outlet syndrome depend on whether the nerve, blood vessels, or both are compressed at the thoracic outlet. Sensory symptoms of nerve compression is the most common, with motor weakness less noted. The sensory symptoms are primarily pain and paresthesia. They are usually insidious in onset and are located in the neck, shoulder, arm, hand, and fingers.

Symptoms attributable to vascular compression include coldness, fatigability, numbness, and some pain. Venous compression is rare and may manifest as edema and bluish discoloration.


The triangle formed by the anterior acalene muscles, the middle scalene, and the first rib through which traverse the subclavian vessels and the brachial plexus remains constant in everyday activites. Symptoms of occlusion can result from various abnormalities such as the following:

  • accessory cervical rib, with or without fibrous extension, marrows the interscalene triangle.
  • the subclavian artery passes through, instead of passing behind, the anterior scalene muscle.
  • thickening of the fibrous band or fascial component of the triangle has occurred because of poor posture [round shoulder posture], hyperextension neck injuries. excessive repititive demands placed on the shoulder [like pitching] or other trauma.


Conservative treatment is the first line of treatment for many musculoskeletal conditions. In the case of thoracic outlet syndrome, physical therapy consult and treatment is mostly effective. Here are some things that a physical therapist would consider:

  • Stress management.
  • Habitual movement and changes in positions as opposed to one static position for long hours.
  • Mobilization and stretching of the cervicodorsal [thoracic] outlet as they may be thickened and contracted, which in turn immobilizes the scalene muscles affecting the excursion of the first rib.
  • Stretches of tightened muscles like the scalenes and pectorals muscles.
  • Strengthening of scapular muscles, particularly the scapular elevators.
  • Treatment program of the cervical spine through manual therapy can also be incorporated.
  • Ulnar nerve and radial nerve glides can be really helpful.

Headaches… and Physical Therapy.


There are two types of headaches – Primary and Secondary.

Primary headcahes include those of vascular origin, such as cluster and migraine headaches. As well as headaches of muscular origin, such as tension-type headaches.

Secondary headaches occur from another source including inflammation and head and neck injuries.

Cervicogenic headaches can benefit from physical therapy because the head pain is usually coming from the neck or cervical spine. Patients who have sustained whiplash or concussion injuries with resulting neck pain can sometimes develop CGH [cervicogenic headache]. In fact, a headache that develops 3 month after the initial concussion are generally not caused by head or brain trauma, suggesting a cervical spine etiology.

Cervicogenic headache is the most common cause of headache among weight-lifters. Headaches can also be referred pain of myofascial or discogenic origin very common among those with postural issues, especially those who are in flexed position on their desk most of the time, working on their computers.

Diagnostic Criteria:

Diagnostic criteria for CGH include headache associated with neck pain and stiffness. Cervicogenic headaches can be unilateral starting form one side of the posterior head and neck, and sometimes associated with arm discomfort on the same side.

Physical Therapy Treatment:

Physical therapy procedures include normalizing the soft tissue and mechanical dysfucntion causing the headache. Thorough evaluation of the head and neck and overall posture can shed some light as to what is causing the headache. Various physical therapy techniques like myofascial tension release, cervical spine mobilization and/or manipulation, suboccipital release technique, postural modification program, among others. Overall treatment is based on the evaluation and diagnosis.


Part of this article is condensed from The International Journal of Sports Physical Therapy, vol 6 number 3, 2011.