Cumulative industrial trauma as an etiology of seven common disorders in the foot and ankle: what is the evidence?

The concept of cumulative industrial trauma as an etiology of orthopaedic disease has recently generated considerable attention in both the medical and legal communities. To clarify the current state of knowledge about the issue as applied to the foot and ankle, we critically reviewed the literature on the etiology of seven foot and ankle disorders commonly involved in compensation litigation in the practice of the senior author: hallux valgus, interdigital neuroma, tarsal tunnel syndrome, lesser toe deformity, heel pain, adult acquired flatfoot, and foot and ankle osteoarthritis. Koch's postulates were appropriately modified and used as a logistic framework to analyze the potential for cumulative industrial trauma to cause foot pathology. In none of the disorders analyzed could cumulative industrial trauma reasonably satisfy even one of Koch's three postulates. We conclude there is currently no unequivocal literature support upon which to invoke cumulative industrial trauma as a clear etiology of these disorders of the adult foot and ankle. The superb evolutionary adaptation of the human foot to prolonged ambulation and the absence of industrial demands that significantly differ from this task likely account for this dramatically reduced vulnerability of the foot to industrial repetitive motion disorders compared to the upper extremity.