1. Combs, Bryan
  2. Heaton, Karen


Musculoskeletal injuries in the occupational setting have significant impact on the worker, employer, and healthcare system. The commercial truck driver (CTD) experiences some of the highest rates of injury, missed days of work, and workers' compensation costs compared with other workers. In this population, the back is most commonly affected whereas shoulder injuries are the second but require 5 times more days away from work. Commercial truck drivers are significantly impacted by shoulder injuries; however, little is known about the unique mechanisms of injury, specific injuries, or possible preventative measures among this group of workers. This article reviews the current state of the science related to musculoskeletal disorders of the shoulder within the CTD population, to provide a better understanding of the true extent of these disorders and their impact, and to create a foundation for future research.


Article Content

The National Institute for Occupational Safety and Health (NIOSH) was established in 1970 with the goal to create new knowledge that advances injury prevention and provides recommendations that prevent injury and illness within the working population (NIOSH, 2013). The National Occupational Research Agenda (NORA) is a program within NIOSH to create partnerships to stimulate the growth of occupational safety research (NIOSH, 2012). NORA created counsels for each of the 10 NIOSH sectors to create guidelines and goals for the development of research and new knowledge within their respective groups. The commercial truck driver (CTD) population is part of the Transportation, Warehousing, and Utilities (TWU) industry sector. In 2009, NORA published a report that outlined four strategic research goals for the TWU sector: (1) Reduce lost workday occupational traumatic injury and fatality rates in the TWU sector; (2) reduce the incidence and severity of work-related musculoskeletal disorders (MSDs) among workers in the TWU sector; (3) improve health and reduce premature mortality among TWU workers through workplace programs and practices; and (4) identify, evaluate, and reduce chemical, biological, and physical occupational hazards and exposures (NORA Transportation, Warehousing, and Utilities Sector Council, 2009).


In 2014, the United States Department of Labor (USDOL) reported the overall incidence rate of nonfatal occupational injuries and illness requiring days away from work to be 100 of every 10,000 full-time workers. Commercial truck drivers had the second highest incidence rate (322.8/10,000) of injury among all occupations (USDOL, 2013), representing a 14% increase from the previous year. Musculoskeletal disorders of the back most commonly are manifested in this population (35.5%), followed by shoulder injuries as the second most common MSD (15.7%) (USDOL, 2013). Workers with back injuries miss 9 days of work per incident compared with workers with shoulder injuries, who miss 46 days per incident (USDOL, 2013). There are also significant financial strains associated with MSDs of the shoulder. Workers' compensation claims related to MSDs of the shoulder are 17% higher than the average claim of all other workers' compensation claims (Davis, Dunning, Jewell, & Lockey, 2014). Davis et al. (2014) also showed that CTDs between the ages of 55 and 64 years had a median cost per claim of $15,300 for shoulder injuries, the highest cost among all age groups and all MSDs.


Musculoskeletal disorders to the shoulder have a significant impact on the CTD population. Even though these injuries account for some of the highest incidence rates, days of work missed, and costs, there is little to no research investigating MSDs of the shoulder in CTDs. This may represent a significant gap in research related to the CTD population and is directly related to the first and second strategic goals of NORA to reduce lost workdays to injury and the incidence/severity of work-related MSDs (NORA Transportation, Warehousing, and Utilities Sector Council, 2009). The purpose of this article was to review the current state of the science related to MSDs of the shoulder within the CTD population to better understand the true extent of these disorders and their impact and to create a foundation for future research with this population.


Understanding the Shoulder

It is important to review the anatomy and function of the shoulder in order to understand the literature relevant to these types of MSDs in this population. The shoulder is a complex joint that is made up of three bones, nine muscles, and eight ligaments (see Figure 1; Skinner & McMahon, 2014). The shoulder is a ball and socket joint that allows for an extreme range of motion (ROM); this motion makes the shoulder more unstable than other joints throughout the body. The healthy shoulder can have up to 160[degrees] of flexion/forward elevation and 60[degrees] of extension, which create a 220[degrees] arc, 180[degrees] of motion from abduction, 70[degrees] of internal rotation, and 90[degrees] of external rotation (Thompson, 2010). Because of this extreme ROM, the shoulder uses both static (ligaments) and dynamic (muscles) restraints to maintain joint stability and integrity.

Figure 1 - Click to enlarge in new windowFigure 1. Shoulder anatomy: (A) anterior view; (B) posterior view. From Tank, P. W., & Gest, T. R. (2009).

The humerus and the glenoid cavity of the scapula form the central joint of the shoulder, the glenohumeral joint. The glenoid cavity is small in size when compared with the humeral head. This is what allows the shoulder to have the greatest ROM of any joint in the body (Thompson, 2010). This can be visualized as a golf ball sitting on a golf tee. It does not take much force to knock the golf ball off, and in the shoulder, this extreme motion creates a mobile but unstable joint. The glenoid cavity is surrounded by a piece of circular cartilage, called the labrum, creating a larger surface area in which the humeral head rests. This cartilage improves the stability; by using the golf ball and the tee analogy, the labrum creates a larger plate top of the tee for the golf ball to sit on. The rotator cuff is the main muscle group responsible for the motion of the glenohumeral joint. It is composed of the supraspinatus (abduction and forward flexion), infraspinatus (external rotation), teres minor (external rotation), and subscapularis (internal rotation) (Thompson, 2010). These four muscles create a capsule around the glenohumeral joint, providing stability as well as motion.


The unique anatomy of the shoulder and its required use in most occupational settings are associated with several risk factors that may result in injury. Some of these risk factors are repetitive motion during work, working with arm in elevated position, small workplaces, long periods of sustained activity, and fatigue (Ferguson, Allread, Le, Rose, & Marras, 2013; Hanvold, Waersted, & Veiersted, 2012; McDonald, Tse, & Keir, 2016; Nordander et al., 2009; Svendsen et al., 2004).


Literature Review

The literature related to MSDs and CTDs was identified by using two common databases: PubMed and CINAHL. The inclusion criteria for this literature search required the publication to be peer reviewed and written in the English language within the last 10 years. The initial search included the keywords "shoulder injury" and "commercial truck driver," which resulted in no citations. The date range was expanded to 25 years, and the key words were adjusted to include "shoulder," "injury," "musculoskeletal disorder," "truck driver," "commercial driver," and "long haul." Using the revised criteria, the search yielded 429 articles. Duplicates were removed (n = 21), and the article titles and abstracts were reviewed to make sure they addressed MSDs within the CTD population. The remaining 45 articles were then reviewed in depth to verify that they evaluated MSDs that included the shoulder. Only five articles were found to address MSDs that included the shoulder in the CTD population, including a report from the U.S. Bureau of Labor Statistics (USBLS, 2014) found during a secondary search of Google Scholar.


Because of the limited search results regarding CTDs and MSDs, a new search using the search terms "shoulder injury" and "occupational" was completed with the same initial inclusion criteria with the goal of finding current research investigating MSDs of the shoulder in non-CTD occupational settings. This search resulted in 233 articles. Duplicates were removed (n = 9), and the titles and abstracts were reviewed to verify that the articles addressed MSDs in the occupational setting and 56 articles remained. These articles were reviewed in their entirety to verify that these publications specifically addressed shoulder injuries within the occupational setting. This left 21 articles that were related to MSDs of the shoulder within the occupational setting.


In total, there were 26 articles identified for inclusion in the literature review (see Figure 2). The available publications were divided into four categories based on research population: (1) research studies related to CTD; (2) research studies of another single occupational population; (3) research studies of multiple occupational populations; and (4) research studies of biomechanics in no particular population.

Figure 2 - Click to enlarge in new windowFigure 2. Literature review flow chart.

Research Studies Related to CTDs

Each of the five publications regarding CTDs investigated correlations and trends related to MSDs within this unique population (see Appendix A). Research has consistently shown that in CTDs, the shoulder has the second highest incidence of injury whereas the back has the highest incidence rate (Davis et al., 2014; McCall & Horwitz, 2005; Smith & Williams, 2014; USDOL, 2013; van der Beek, Frings-Dresen, van Dijk, Kemper, & Meijman, 1992).


The first study to investigate the incidence of MSDs in CTDs was published in 1992. It was a nonexperimental, descriptive design study that assessed complaints using the Periodic Occupational Health Survey (Broersen, Weel, & van Dijk, 1989) with 534 CTDs in England. The third most common body part with complaints of pain among CTDs was the shoulder (28%). van der Beek et al. (1992) indicated that the 28% of CTDs had complaints of shoulder pain while the back (47%) and neck (29%) were the only areas with more complaints.


A study of reported shoulder injuries within a large goods transport company in Denmark (McCall & Horwitz, 2005) showed that, within the CTD population, falls from height were the most common mechanisms of injury. Stepping off of an edge was the trigger for these falls 33% of the time. A unique finding in the research was that 51% of all injuries happened to workers with less than 1 year of experience (McCall & Horwitz, 2005).


A study of ergonomic risks and discomfort of CTDs while performing common tasks outside of the cab indicated that the right shoulder is associated with the most complaints of physical discomfort whereas the left shoulder was associated with the third most common complaints (Reiman, Pekkala, Vayrynen, Putkonen, & Forsman, 2014). The mechanism of injury most commonly associated with shoulder discomfort was overexertion and/or repetitive motion and was most often reported during unloading cargo at the delivery site (Reiman et al., 2014).


Two studies evaluated the effects of MSDs on CTDs using data from workers' compensation claims. The shoulder was associated with one of the highest incidence rates of work-related injury; these claims were some of the costliest (Davis et al., 2014; Smith & Williams, 2014). Commercial truck drivers had a higher incidence of injury to the shoulder than nontrucking populations. They also had an increased risk of developing partial or total disability related to occupational MSDs (Smith & Williams, 2014). Davis et al. (2014) reported that CTDs had a higher number of claims related to the shoulder, and these claims had a 20% higher mean cost compared with any other profession. In fact, the commercial driver industry sector had the highest average cost per workers' compensation claim for all age groups and all occupational sectors (Davis et al., 2014).


A 2013 USDOL report addressing Occupational Safety and Health Administration (OSHA) reportable injuries and illnesses indicated that the second most common injury reported by CTDs was to the shoulder (15.7%), with each incident leading to an average of 46 missed days of work. Although work-related back injuries were found to be two and half times more likely than shoulder injuries, shoulder injuries required five times as long to recover compared with back injuries. The most common type of injury was either a sprain or strain, and the mechanism or event with the highest incidence was overexertion or body reaction (USDOL, 2013).


Research Studies Including Different Occupational Population

Several different studies investigated shoulder injuries in occupational settings outside of the CTD population. Of these publications, 10 concentrated on an individual occupation (see Appendix B). Three studies evaluated MSDs of the shoulder within the construction worker population. The shoulder was one of the two most commonly injured regions of the body in this group (Borstad et al., 2009; Soares, Jacobs, Minna, & Mika, 2012). Construction workers' complaints of shoulder pain ranged from 17.8% to 55.6% (Borstad et al., 2009; Soares, Jacobs, Minna, et al., 2012). In this group, shoulder discomfort was more common when working above shoulder level and there was some evidence that the type of foundation the worker was standing on may have caused a difference in discomfort (Phelan & O'Sullivan, 2014). This difference in discomfort could have been due to the compensation of shoulder muscles while on different work platforms. An example of this is the changes in deltoid muscle use while standing on a ladder versus solid platform (Phelan & O'Sullivan, 2014). Injury prevention was evaluated in two of the studies, and it was found that the use of occupational health services at job initiation (Soares, Jacobs, Minna, et al., 2012) and preventative exercise programs (Borstad et al., 2009) may be useful in decreasing complaints and MSDs of the shoulder. When occupational health services, such as education on work posture, performance, or tools, were received by construction workers, there was a significant decrease in the incidence of MSDs to the shoulder or arm (p = .024; Soares, Jacobs, Minna, et al., 2012).


Electricians often worked with their arms raised above shoulder height, and the shoulder was the most common body region where they experienced pain (12.69%; Trotta, Ulbricht, & Silva, 2014). Interestingly, taller utility workers experienced less pain unloading and loading ladders than shorter workers doing the same activity; pulling an item above shoulder height required more force (Soares, Jacobs, Moriguchi, et al., 2012). The force required during the simulated task of pulling an object is increased with changes in elevation (Soares, Jacobs, Moriguchi, et al., 2012), and this represents daily tasks performed by electricians in the field (Moriguchi, Carnaz, Miranda Junior, Marklin, & Gil Coury, 2012).


In 2014, it was shown that the second most common MSD within the nursing workforce was related to the upper extremity (Bhimani, 2016). Shoulder injuries in nurses were explained by the pushing and pulling of patients. This finding may be related to CTDs when compared with the finding that the main complaints CTDs have while loading and unloading goods occurred during pushing-and-pulling motions (van der Beek et al., 1992). In the nursing population within this study, 48% of the participants acknowledged having an MSD, yet they did not initially report it because they felt it was a minor injury (Bhimani, 2016). Taxi drivers are also at an increased risk for MSDs of the shoulder. A study completed by Bulduk, Bulduk, Suren, and Ovali in 2014 found that taxi drivers had an increased risk of exposure for MSDs of the neck, shoulder, and arm.


Research Studies of Multiple Occupational Populations

Six studies evaluated MSDs of the shoulder in populations that included more than one occupation (see Appendix C). As was found in studies looking at individual occupations, the shoulder was a common body region affected by MSDs (Asundi, Harbin, Shenoy, Garcia, & Olson, 2011; Bovenzi, 2015; Hegmann et al., 2014; Herin, Vezina, Thaon, Soulat, & Paris, 2012; Nordander et al., 2009). A study evaluating custodial staff found that the most common mechanism of injury seen in MSDs of the shoulder were sprains/strains related to overexertion (Asundi et al., 2011). Also, workers in occupational settings that require them to perform repetitive tasks within a constrained environment were more at risk of developing MSDs of the shoulder than in occupations with varied environments and more mobility (Herin et al., 2012; Nordander et al., 2009).


Several mechanical factors have been shown to be related to MSDs of the shoulder. In patients with chronic shoulder pain, 24% were seen to have constraints in movement and 24% experienced a physical space constraint when having to apply forceful movement (Herin et al., 2012). Occupational settings that require a worker to experience whole-body vibration, lift greater than 15 kg more than 45 minutes in a workday, or work with hands above head for more than 60 minutes in workday have been shown to be significantly related to shoulder pain (Bovenzi, 2015).


The variations in case definitions can have a possible impact on epidemiological studies regarding shoulder injuries. Hegmann et al. (2014) discussed the difficulty conducting epidemiological studies related to MSDs of the shoulder by highlighting how the differences in definitions of injuries complicate investigations. In their study, they found that 23% of the time rotator cuff tendinitis presented only with pain and 8% of the time it presented with pain and a positive supraspinatus test (Hegmann et al., 2014).


Research Studies of Shoulder Biomechanics

Some research was not conducted on a specific population group but rather evaluated the biomechanics of the shoulder during routine tasks commonly seen in the working environment of CTDs (see Appendix D). The CTD often deals with many different environmental demands that cause physical stress or strain: whole-body vibration while driving, loading and unloading cargo, using tarps and chains to secure the cargo, and pushing and pulling heavy weights. Many of these activities require them to work with their arms above shoulder level. Elevating the arm to shoulder height or above increases stress and load of the muscles that cross the shoulder joint (Antony & Keir, 2010; Au & Keir, 2007; Blache, Desmoulins, Allard, Plamondon, & Begon, 2014). When the arm raises from 30[degrees] to 90[degrees], shoulder muscle activity increases by 84% (Antony & Keir, 2010). Blache et al. (2014) showed that the supraspinatus and infraspinatus muscle force decreased as the arm moved from shoulder level to eye level while the subscapularis muscle force increased.


Physiological fatigue had an effect on shoulder muscle function, joint ROM, and adaption (Fuller, Lomond, Fung, & Cote, 2009; McDonald et al., 2016). As the shoulder became fatigued, the amount of flexion during tasks decreased while abduction increased (Blache et al., 2014). Muscle activity and joint ROM were significantly affected during tasks that required pushing and pulling when fatigued (McDonald et al., 2016). During activities that required the arm to be above shoulder height, the muscle that elevated the shoulder became fatigued quicker than the others muscles of the shoulder (Fuller et al., 2009).



The purpose of this literature review was to evaluate and assess what research is available regarding MSDs in CTDs concentrating on the shoulder and what has been learned from this research. Because of the limited research evaluating the shoulder of CTDs, the review was expanded to include research evaluating the shoulder in occupations outside the CTD population. On the basis of the current research, the shoulder is consistently the second most common body part injured in CTDs (Davis et al., 2014; Smith & Williams, 2014; USBLS, 2014; van der Beek et al., 1992). This is a significant finding because it was found in five different populations that included CTDs. This review has shown that shoulder injuries have a high incidence rate and there is a significant impact on CTDs and their industry. Injuries to the shoulder require an extended time away from work when compared with injuries involving other body regions (Davis et al., 2014; McCall & Horwitz, 2005; USDOL, 2014) and are among the most expensive workers' compensation claims (Davis et al., 2014; McCall & Horwitz, 2005; Smith & Williams, 2014).


Despite the impact of shoulder injuries to CTDs shown in this review, significant gaps in the literature were still noted. First, the studies discussed common injured body regions, common causes of injuries, and time of work missed; however, none looked at these variables in relation to each other. Even though sprains/strains are some of the most common types of MSDs, it is not known whether they are the most common mechanisms of injury of the shoulder. It was not shown how many days of work are missed for a sprain/strain when compared with a fracture or contusion, or if overexertion was the most common mechanism for shoulder injuries. This information is critical to understanding MSDs of the shoulder.


A second important gap is that there is minimal research investigating MSDs of the shoulder in CTDs. Research of similar occupational stressors on the shoulder in different professions (e.g., nursing, construction work, and electricians) has indicated some of the highest incidence rates of MSDs in occupational groups (Bhimani, 2016; Borstad et al., 2009; Bulduk et al., 2014; Soares, Jacobs, Moriguchi, et al., 2012; Trotta et al., 2014). Many things can be learned from the current research in other occupations. Occupations that require repetitive tasks and environments that require tasks to be performed above shoulder height increase stress on the shoulder and may lead to the onset of MSDs (Antony & Keir, 2010; Au & Keir, 2007; Blache et al., 2014; Borstad et al., 2009; Reiman et al., 2014; Soares, Jacobs, Minna, et al., 2012). It has also been found that individuals experiencing fatigue compensate by altering shoulder biomechanics, further stressing the shoulder joint. (Fuller et al., 2009; McDonald et al., 2016).


It is important to understand that although these professions may experience similar stressors, the stresses are not exactly the same as those experienced by CTDs. There is a lot to be learned regarding shoulder injuries in CTDs. This review has highlighted the gap in current research regarding CTDs and reinforces the need to develop nursing research to create new knowledge and help fill this gap. This research may be used to determine common characteristics associated with shoulder injuries in CTDS, define the specific biomechanical function of the CTDs' shoulders related to the unique work environments, and determine whether there are risk factors or variables that are associated with or contribute to shoulder injuries in the population differ from other populations.


This research will inform the development of interventions to decrease injury rates or to speed recovery. Occupational services have been shown to be effective in decreasing shoulder injuries and complaints in occupations other than CTDs (Asundi et al., 2011; Soares, Jacobs, Moriguchi, et al., 2012). These studies again highlight the serious gaps in the current understanding of shoulder injuries in CTDs.



This review has shown that shoulder injuries have a significant impact on CTDs including missed work, increased financial costs, and possible disability (Davis et al., 2014; Smith & Williams, 2014; USBLS, 2014). Many studies have been published outside of the CTD population that not only highlight high incidence rates of MSDs of the shoulder but also investigate the epidemiology, biomechanics, and preventative measures. Within the CTD population, there is a need for the development of new knowledge of the risk factors, biomechanics, and variables associated with shoulder injuries among CTDs. Once this knowledge is synthesized, the goal will be to develop specific prevention, intervention, and rehabilitative strategies that will help create evidence-based practice. This evidence-based practice could positively impact the CTD population.




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