A recent study by Mutualités Libres, a Belgian health insurance fund, found that musculoskeletal disorders (MSDs), together with psychosocial conditions such as burnout, stress and depression, remain among the leading causes of work incapacity and disability in Belgium. In an interview with MediQuality, a Medscape Network platform, Patrick Durez, MD, PhD, head of rheumatology at Cliniques Universitaires Saint-Luc in Brussels, explained why the problem is so difficult to address.
The report shows that the number of new cases of work incapacity linked to MSDs has not declined over the years. Is that surprising?
This is not unique to Belgium. MSDs are one of the leading causes of functional disability across Western societies. Their burden is still widely underestimated. They are highly prevalent and very costly. The aging of the working population is probably the main factor, since these conditions increase with age. But that is not the whole story.
The study highlights a 44% increase between 2018 and 2024 in knee osteoarthritis diagnoses leading to work incapacity. What other factors might explain this?
We should not underestimate the impact of obesity. Metabolic syndromes are more common today. Sedentary lifestyles also play a role. In the past, osteoarthritis was often less symptomatic because people were more physically active. In addition, our relationship with pain has changed. Pain sensitivity is more pronounced today than it was a few decades ago, partly due to greater exposure to stress, which can amplify pain perception.
Does this also explain the rise in incapacity cases linked to rotator cuff syndrome (+40%) and epicondylitis (+18%)?
These are mechanical tendinitis conditions, related to physical strain, but the concept of pain threshold is also important. People report pain more quickly because stress and sleep disorders worsen tendinitis.
So the two main groups of conditions leading to work incapacity are linked?
Absolutely. We live in a society where stress is part of daily life. If you are happy at work and suffer from an MSD, you can cope with it more easily. Conversely, if you are unhappy at work, it worsens the condition. This creates a vicious circle, with both physical and psychological health deteriorating.
Which occupations are particularly at risk for MSDs?
Those working in construction, where jobs demand physical strength and repetitive movements, are especially exposed. Among office workers, IT professionals face higher risks for back pain, neck pain, and shoulder tendinopathy. They spend long hours sitting and are often under stress, which increases muscle tension. Farmers are another interesting case. Historically, they have shown rates of osteoarthritis 10-15 times higher than the general population. Yet they do not complain more than average. This may reflect a lower sensitivity to pain, linked to working in a profession they are passionate about. That said, in recent years we have seen this is not the case for everyone, with some reaching their limits.
Does being self-employed also play a role?
Yes. The report shows that employees and the self-employed experience work incapacity differently. Except in a critical situation, a farmer, for example, has little choice but to get up in the morning and work. However, now that the self-employed in Belgium benefit from stronger social insurance coverage, they too are more likely to enter work incapacity.
From a prevention perspective, what strategies should be prioritized to curb the rise in work incapacity linked to MSDs?
This is a genuine societal problem. To be effective, solutions need to be tailored to the specific risks of each occupation. Some companies already adapt equipment to prevent poor posture, for example. More broadly, every worker should ideally have access to a preventive program that includes regular physical activity, weight control, and relaxation techniques. Such initiatives should be introduced directly in the workplace, and as early as possible. Employees should benefit from them from the age of 30. Waiting until 55 makes these problems much harder to manage. As I mentioned earlier, workplace well-being must also be addressed. And we must not overlook the medical dimension of rising incapacity.
What do you mean?
We must acknowledge that doctors share part of the responsibility. Writing a medical certificate takes 5 seconds; refusing one takes 10 minutes. That is a problem.
The report suggests developing recommendations for doctors to give them clear reference points on the optimal length of sick leave. Could that help?
It is not a bad idea, given that competition exists between doctors, with some patients actively seeking out the most lenient when it comes to extending leave. For 10 appointments for back pain, you might get 10 different opinions. It would be helpful to bring occupational health physicians and specialists together to agree on benchmarks for how many days of incapacity should be prescribed for each condition. That said, the issue is complex, as cases are often complicated by burnout or depression. In any case, I believe occupational health doctors need to be more involved in the process.
How so?
They do not currently have access to the patient’s medical record. This is a critical problem, as reports can be highly inconsistent and diagnostic errors do occur. In addition, some patients present only the information that suits them to the occupational health doctor, which is not the whole medical truth. Access to the medical record would allow for a much clearer picture of the patient’s pathway. Alongside this issue, surgery also deserves attention.
Do we operate too quickly for MSDs?
Most doctors do their work very well, but we know competition between hospitals is fierce. This leads some orthopedic surgeons to operate more readily. Yet postoperative pain can itself justify incapacity or disability claims. Low back pain is a good example: we know that operated back pain often leads to more chronic back pain. Surgeons are aware of this, but some still proceed without fully validating the indication. It is similar with epicondylitis. There is currently no national recommendation on how to manage it.
It is worth recalling that surgery in these cases is not bound by strict selectivity criteria. This reflects a degree of liberalism in treatment decisions. Some doctors use platelet-rich plasma injections, despite the lack of scientific validation. The same is true of many pharmacy products marketed for osteoarthritis. The complexity of MSDs lies in this variability of care, which depends in part on whether a patient consults in a private clinic or an academic hospital.
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