Practice Management Toolbox

Training the endo-athlete – an update in ergonomics in endoscopy


As physicians, we work hard to take excellent care of our patients. Years of thoughtful practice and continuous learning allow us to deliver the best that medicine can provide. We often take poor care of ourselves, which can lead to burnout and physical injuries. As gastroenterologists, we spend substantial time performing endoscopic procedures that require repetitive motions such as flexion and extension of the wrist and fingers and torsional movements of the right hand, which may lead to overuse injuries. The volume of endoscopic procedures performed by a typical gastroenterologist has increased significantly in the past 20 years. Moreover, experts predict that by 2020 we will have too few endoscopists to meet clinical demands.1 It is imperative that we do whatever possible to ensure overuse injuries do not prematurely prevent us from providing much-needed care. One way to achieve this goal is to focus on ergonomics. The study of ergonomics, derived from the Greek words ergo (work) and nomos (law), seeks to optimize the interface between the worker, the equipment, and the work environment. This article reviews basic ergonomic principles that endoscopists can apply today and possible innovations that may improve endoscopic ergonomics in the future.

Breadth of the problem

Examinations of injuries related to endoscopy are limited to survey-based and small controlled studies with a 39%-89% overall prevalence of pain or musculoskeletal injuries reported.2 In a survey of 684 American Society for Gastrointestinal Endoscopy members examining injury prevalence and risk factors,3 53% experienced an injury believed to be definitely or probably related to endoscopy. Risk factors included higher procedure volume (more than 20 cases/wk), greater number of hours spent performing endoscopy (more than 16 h/wk), and total number of years spent performing endoscopy2,4. Community practitioners reported injuries at higher rates than those in an academic center. Other suggested but unproven risk factors include age5, sex, hand size, room design, and level of training in ergonomics and endoscopy2. Injuries can be severe and may lead to work load reduction, missed days of work3-5, reduction of activities outside of work, and long-term disability2.

Dr. Manish Singla Walter Reed National Military Medical Center, Bethesda

Dr. Manish Singla

Most surveys reflect symptoms localized to the back, neck, shoulder, elbow, hands/fingers, and thumbs likely from overuse causing strain and soft-tissue microtrauma6. Without time to heal, these injuries may lead to connective tissue weakening and permanent damage. Repetitive hand movements in endoscopy include left thumb abduction, flexion, and extension while manipulating dials and right wrist flexion, extension, and deviation from torqueing the insertion tube. The use of torque is a necessary part of successful colonoscopy; during scope reduction and maneuvering through the sigmoid colon, torque forces and forces applied against the wall of the colon are highest. When of sufficient magnitude and duration, these forces are associated with an increased risk of thumb and wrist injuries. These movements may result in “endoscopist’s thumb“ (i.e., de Quervain’s tenosynovitis) and carpal tunnel syndrome2. Prolonged standing and lead aprons are implicated in back and neck injuries;2,7-9 two-piece aprons,7,10 and antifatigue mats7 are recommended to decrease pressure on the lumbar and cervical disks as well as delay muscle fatigue.


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