The format of the Third Edition echoes that of the prior editions. The book is divided into three sections: The Predicament, The Patient, and The Claimant. My approach to the study of occupational musculoskeletal disorders has been structured in this fashion for some time, thanks to something of an intellectual epiphany and no thanks to my medical education, albeit elite and privileged. It took nearly a decade after graduating from medical school to realize that a patient who leaves the office or hospital becomes a person, again, who is irretrievably changed by the treatment experience. It took nearly the same amount of time to realize that, for most conditions, the choice to be a patient is just that, a choice. Western medical education and western medicine is chauvinistically patient-centered. Western medicine’s banner is that the care of the patient is primary, not the care of the person who has chosen to be a patient. People can be symptomatic and choose to remain people. Once that notion rises to the fore, its corollary becomes the crux; the difference between being challenged by symptoms and being ill from symptoms is in the choice of recourse. For 20 years I have pursued the answers to such questions as how can some people manage to find the wherewithal to eschew recourse, others choose to be patients, and still others find their circumstance so dire that gainful employment is at risk? It is fortunate that my background in rheumatology rendered musculoskeletal disorders the arena in which I was most comfortable tackling these questions. It turns out that the analysis in this arena is telling, and its messages are widely generalized. The choice between being challenged and being ill is seldom driven by the intensity or quality of symptoms. The choice is most often driven by the wherewithal to eschew recourse when overwhelmed by the confounders to coping that hide in the context of one’s course of living.

Every one of us will have musculoskeletal pain. Almost always, the pain is in a discrete musculoskeletal region: a limb, the neck, the low back, the shoulder, and so forth. Furthermore, we experience these morbidities when we are otherwise well and feel otherwise well. These regional musculoskeletal symptoms are the focus of this monograph. They are vastly different in implication from systemic musculoskeletal symptoms, which occur as manifestations of an underlying systemic disease such as rheumatoid arthritis or systemic lupus erythematosus. Systemic symptoms can also be asymmetric and even discrete at times, rendering the distinction challenging. To do justice to the reader, clues to making the distinction are provided throughout the text. However, regional musculoskeletal symptoms are the focus of this volume; the reader may refer to any of the many standard treatises on systemic rheumatic diseases to pursue interests in that direction.

Furthermore, and by definition, we have regional musculoskeletal symptoms in the absence of discrete external trauma or, for that matter, any recognizably
violent precipitants. The symptoms arise in the course of activities that are customary, as well as customarily comfortable. Nonetheless, the precipitation of some of these episodes seems explicable, even sensible; we can ascribe the onset of symptoms to some particular usage or overusage without challenging the bounds of experience or reason. Gardeners, recreational athletes, parents of young children, all of us, in fact, notice our symptoms when some musculoskeletal region in use hurts, and all of us are prone to ascribe cause to such use. Often, the pain causes us to wonder why a customary usage had not caused the pain in the past. When the pain is particularly intense or prolonged, or when it is unfamiliar in quality or location, we must pause. Every one of us is forced to contend with such a predicament. We must consider its implications, we must consider our options, and we must process the predicament to choose our response.

I wish there were something I could do, suggest, or prescribe to obviate these experiences. I am aware of none. However, there are personal options useful in the quest for palliation, some of which are not intuitively obvious. For example, because nearly all of these predicaments are exacerbated with particular usages of the involved musculoskeletal region, awareness of particularly difficult usages can be valuable. How many of us with a backache are aware that leaning forward 20 degrees while sitting can rival lifting a suitcase in stressing the low back? You will cope better with attention to posture. The corollary insight is daunting and is the reason for my pessimism regarding the incidence of musculoskeletal predicaments; the biomechanics of normal, everyday usage place such enormous stresses on the musculoskeletal system that any region prone to hurting for any reason can scarcely escape our perception. If you have a backache, even leaning forward 20 degrees becomes a challenge.

Regional musculoskeletal predicaments are not simply painful. Often, restriction in musculoskeletal function will confound the discomfort, providing additional challenges in daily life that we could well do without. This is true whether we have a backache, neck pain, or pain in an extremity. To some extent, the very nature of the predicament is to restrict function and cause incapacity. Therefore, making it through the day with musculoskeletal discomfort that is exacerbated with usage is always a challenge. If we can find no way to overcome or circumvent the incapacity, we have a disability. Even incapacities can be circumvented sometimes; for example, we might “run around our backhand” until our lateral elbow pain subsides yet still play a credible game of tennis. If we find we must forego golf until our backache remits, we have chosen to be temporarily disabled in terms of this particular avocation.