Out on a limb

When a team of podiatrists complained of work-related upper limb disorders
(WRULD), an OH nurse carried out a survey to investigate the source of the
problem, by Paula Layzell

An OH department that provides a range of services to Norfolk NHS Trusts
realised that staff in one of its divisions, the foot health service team, were
reporting symptoms of work-related upper limb disorders (WRULD).

The department ruled that further investigations should be carried out to
highlight any potential problems after being alerted by an OH adviser.

It was decided that a survey should be carried out on the effects of their
work and its relevance to the condition. It also sought to come up with
preventive solutions to ease the problems.

In addition to servicing the region’s trusts, the Centre for Occupational
Health, which is based within the trust itself, also provides OH services to
the Norfolk Fire Service and a variety of private businesses. It consists of
eight OH advisers, three practice nurses and five OH doctors, plus an OH
consultant physician. A varied skills mix of admin and clerical staff support
the OH nurse practice manager.

The foot health service team – referred to as podiatrists – comprise 38
clinical staff and three technicians who serve most of Norfolk – the Norwich
Community Hospital, small local hospitals and GP practices. Many podiatrists
work alone in rural areas with a varied number of clients, many of them

After members of the foot health team complained of symptoms of WRULD, the
OH department prepared a questionnaire, with input from the clinical governance
team for podiatrists and health and safety. This aimed to establish if the
team’s working practices were causing any health problems. Upper limb disorders
are caused by repeated actions calling upon an undesirable force on muscles,
tendons and joints1.

The limb is usually capable of carrying out such force, providing the action
is for short periods only and incorporates short rests or change of task
breaks. The main sites affected are the fingers, hands, wrists, elbow and

Podiatrists often exert force while adopting difficult postures – they need
to force patients’ feet to maintain skin tension while performing certain
procedures – debridement, for example.

Recognising the problems, assessing the hazard and trying to reduce the
risks can often prevent a serious WRULD problem developing. Unfortunately, only
one podiatrist contacted occupational health when their hands became so painful
that they couldn’t open a jar or spread butter on a slice of bread.

They had only sought help after experiencing high levels of discomfort, even
though the problem had been getting progressively worse over a considerable
length of time. The condition was helped by wearing a splint for a short period
and a course of physiotherapy. And changing the nail clipper-type tool
generally used with a spring tension, to a small barrel tension, significantly
reduced the problem.

Although there is no legal requirement for health surveillance in respect of
WRULD, the Health and Safety at Work Act 19742, Section 2, places a general
duty on the employer. If a hazard is identified, then the Management of Health
and Safety at Work Regulations 1993, Regulation 3, places a duty on employers
to carry out a risk assessment.

Eight podiatrists piloted the questionnaire before all the foot health care
workers’ views were canvassed. This pilot revealed one vital question had been
omitted – how many patients the individual usually sees per day. The
questionnaire was amended accordingly.

Everyone in foot health services was given the opportunity to take part in
the questionnaire. The podiatrists were informed, both verbally and in writing,
that the information collected would form part of their health surveillance
records and would be kept together with their confidential health records.

Thirty-two questionnaires were returned, representing a response rate of 78
per cent. According to researchers Burns and Groves, this is a good response
rate and can support valid research4. Eight specific areas were considered in

– Age range

– Hours worked per week

– Average number of patients seen per day

– Average length of time gripping, squeezing and pinching per day

– Length of activity without a break

– Break taken between activity

– Parts of the upper body affected

– Whether seen by a healthcare professional

Health surveillance results

Age range
Workers in this area tended to be in the 21 to 40 age group. This presented
the question of why? Is the fact that the age range is between 21 and 40
because the job suits the lifestyle of people of that age? Is it because people
leave at around 40 because of work-related issues or because the intake tends
to be younger?

Hours worked per week
This revealed that the majority of foot health workers are employed on a
full-time basis.

Average number of patients seen per day
Fourteen podiatrists (44 per cent) attended 15 to 20 patients each during
the course of a 6.5-hour working day. Podiatrists work 36.5 hours per week, so
seeing 20 patients each day averaged out at 21.9 minutes per patient or 29.2
minutes if only 15 were seen.

An average clinic list would largely be structured with 20-minute
appointments, some 30-minute ones, with an hour for lunch. The half-hour slots
are sometimes used for assessments at 15 minutes each. No treatment is given
during an assessment; it is purely used for clerking patient details.
Podiatrists need to try to structure their clinics to enable a variety of tasks
to be spread over the working day.

Many of the patients are slow when walking and have difficulties removing
footwear, which increases the pressure on the podiatrists.

Average length of time spent gripping, squeezing and pinching per day
This may seem like an imprudent question to ask podiatrists, as this is the
nature of their work, but the question was posed to establish if they spent the
whole working day of 6.5 hours (excluding a lunch break of one hour) performing
the same task. The results showed that a total of 20 were engaged in this sort
of task.

Length of activity without a break
Nine podiatrists or 28 per cent worked for up to 20 minutes without a
break. The same number then had a five-minute break, and usually quickly wrote
up the patients notes, by gripping a pen.

Break between activity
Sixteen of the podiatrists questioned (50 per cent) had a 5-10 minute break
between patients, but then performed a range of tasks still involving gripping
– reading case notes, turning pages, etc.

Parts of upper body affected
Some of the workers declared they had significant aches and pains in more
than one part of their upper body. Adding these statistics together, the survey
revealed 21 podiatrists (66 per cent) have problems with either their hands,
wrists, fingers and thumbs. Many stated these interfered with the activities of
daily living – opening jars, playing squash, etc.

Whether seen by a healthcare professional

Three of those in the survey (or 9 per cent) had undergone some type of hand
surgery and seven – or 22 per cent – of all workers had sought advice from
their GP. Some workers revealed they have seen more than one professional,
while others in this group had only seen one, a hospital consultant, prior to
surgery, for example. It was assumed this excluded an initial appointment with
a GP, so this was not included in the statistics.

The survey’s conclusions

The survey identified that podiatrists experience a variety of limb and
joint aches and pains through the very nature of their work. This means there
is a need for health surveillance to identify potential problems in these
individuals before it affects their daily activities.

Training was needed to specify how podiatrists can help themselves within
their working environment. Potential problems cannot always be eliminated, but
the trust was keen to see if anything further could be done to reduce these.

The sample size was small, but it included all the healthcare workers.
However, if the survey was to be repeated, there is one more question that
should be included – what, if any, are the team’s hobbies outside of work? Many
hobbies have the same type of movements – knitting, sewing, painting, racket
sports and DIY, for example – and these may contribute to the problems experienced.

The survey highlighted the need for health surveillance within the foot
health services to improve their working practices. Five groups of key people
needed to be involved:

– All foot healthcare employees

– Managers

– Health and Safety

– OH

– Physiotherapy/manual handling advisers.


The recommendations made were:

– To look at instruments used. Sizes and pressures involved need to be
comfortable for the user and the instruments need to be examined regularly to
determine if they are still working efficiently and are sharp enough. This
recommendation has already been implemented. It is the clinician’s
responsibility to inform their manager when they require fresh instruments.

– The clinic list. Allocated appointments should be made giving some
consideration to each patient’s needs. This allows flexibility in booking
patients in with longer appointments, and does rely on the clinician organising
their own list.

– Task orientation. The structure of the working day needs to be organised
so repetitive tasks are not being performed all day. Again, the clinicians need
to organise this in their own lists. However, the type of work performed will
always mean that a large part of their day will be focused on treating

– Podiatrists need to alert their line manager to any upper limb problems as
early as possible, not wait until the next review.

– Ergonomics. Look at the workspace, including the chair and couch being
used, to obtain the most comfortable and adjustable individual working height.
Podiatrists should also be aware of their posture while working.

– Education and training must be ongoing, in line with the current best

– Breaks need to incorporated into the working day, whether personal or
task- orientated. Clinicians have the flexibility to organise their time, but
will often ‘see the patients’ rather than protect themselves with appropriate

The survey identified a hazard, which will need continued health monitoring
and further audit.

Practice changes implemented since original survey

– Appointment times for clients have been reviewed and treatment time is
allocated according to the individual client’s requirements. Although, in
theory, this had been the case for some years, the change actively encourages
clinicians to organise their time more carefully.

– Information is to be given to patients in leaflet form, so they become
active participants in their own treatment, empowering them to help themselves
– such as information on using long-handled nail files to keep nails short.
Patients are also asked to consider if they can remove and replace their
elastic stockings before and after their appointment.

– Changes in working practice are being implemented to look at discharging
clients earlier. Much time is spent in callus debridement (removal of dead and
hard skin) while the root cause needs to be addressed – the client should be
referred for correctly fitting shoes. It is recognised that the need to carry
out manual debridement will not go away.

– A change in treatment emphasis means people will potentially exit the
service faster, but the overall demand is unlikely to change.

– The primary care trust is divided into three geographical areas and a
clinical manager for foot health services has been appointed for each area.
They will assist in education, training and supervision, including regular
meetings with OH.

– A poster is being designed with information on how to access OH services
and the importance of reporting symptoms early. The structure of the working
day is being revised to ensure task breaks can be incorporated to try and
reduce the repetitive task workload.

– The podiatrists have a selection of instruments to choose from, but the
clinical governance lead will continue to liaise with instrument manufactures
to see if changes can be made to instrument ergonomics. It is the clinician’s
responsibility to maintain the instruments, which includes treating them with
the recommended surgical lubricant supplied by the trust.

Paula Layzell RGN, Dip. H E Nursing worked until recently in the Centre
for Occupational Health at the Norfolk and Norwich University Hospital. She now
works as an OH adviser for child support agencies in the East Anglia area

Thanks to clinical lead Julian Varney and NNUHT OH manager Sue Smith


1. Work-Related Upper Limb Disorder, a Guide to Prevention, The Health and
Safety Executive (1999) HSE, Sudbury, Suffolk, U K

2. Health and Safety at Work etc. Act, The Act Outlined, The Health and
Safety Commission (1993), Sudbury, HSE books

3. The Management of Health and Safety at Work Regulations (1999) Approved
Code of Practice and Guidance, The Health and Safety Commission, Second ed.
Sudbury, HSE books

4. Understanding Nursing Research Burns N, Grove S (1995), W B Saunders Co,

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