Workplace Violence as a Risk Factor for Musculoskeletal Disorders: Implications for Integrated Prevention

Authors: Paige DeBaylo, PhD and Kenna Stanley, MA

Printable version: Workplace Violence as a Risk Factor for Musculoskeletal Disorders: Implications for Integrated Prevention (PDF)

Musculoskeletal disorders (MSD) remain a leading cause of work-related disability and lost work time. Typically, physical risk assessments and physical risk management have been the hallmark of ergonomists’ jobs in industry. As a result, ergonomists’ coverage of psychosocial hazards or other risks for MSD in the workplace has been more narrow. Yet, research from CRE-MSD, the National Safety Council and others indicates the role of non-physical or non-traditional risk factors, including psychosocial stressors and organizational conditions, are important contributors to the cause and persistence of MSD.1, 2

Workplace violence, which involves any act or threat of physical violence, harassment or other threatening, disruptive behavior that occurs at work, represents a risk not yet fully integrated into MSD prevention frameworks or in how MSD risk factors are defined. While hostile work environments have been explored in relation to MSD,5,8,10,11 workplace violence is not often directly or indirectly linked with MSD risk. Given that many U.S. workers are exposed to workplace violence, with 77,780 workplace violence injuries in 2023-24 alone, and a rise of workplace violence in Canada in recent years, this integration of workplace violence as a risk for MSD is worthy of exploration. Further, because workplace violence and MSD share common upstream causes, they should be addressed through integrated, systems-level interventions rather than siloed programs.

Proposed Conceptual Pathways Linking Workplace Violence and MSD
There are several pathways in which workplace violence could contribute to MSD, either directly or indirectly through other mechanisms, such as through changed behaviors or stress (Figure 1).

Diagram showing potential pathways linking workplace violence and MSD

Figure 1: Potential pathways linking workplace violence and MSD

Workplace violence may act as a(n):

  • Direct exposure, which can contribute to the likelihood of developing an MSD
    • Physical assault can cause an immediate injury (e.g., restraining a violent customer or a patient)
    • Posture adjustments (e.g., “fight or flight” posturing) or movements to defend oneself from physical assault could be awkward and contribute to an MSD
  • Indirect exposure, influencing musculoskeletal health over time
    • Chronic exposure to violence at work (either directly to the worker or from witnessing violence) can increase other non-physical risk factors like stress, anxiety, fatigue, levels of burnout, low morale and sleep disruptions, which can contribute to the likelihood of developing an MSD
    • Chronic stress can also result in the following, which increases the likelihood of MSD:2,4
      • Muscle tension
      • Altered pain processing
      • Delayed tissue healing
      • Reduced pain tolerance

While not explicitly mentioned in the accompanying infographic on workplace violence and MSD, in which a pathway from workplace violence to MSD is proposed, there may also be a less explored relationship between MSD and workplace violence. For example, suffering from an MSD might lead to an increased likelihood of workplace violence, given the relationship found between musculoskeletal injuries and psychological effects such as increases in anxiety, depression or post-traumatic stress after sustaining an MSD.3 More research is needed to explore this bidirectional linkage between MSD and workplace violence.

Ways to Incorporate Workplace Violence Awareness in MSD Prevention Efforts
Many of the same conditions that elevate MSD risk also increase the likelihood and impact of workplace violence.6,9 Organizational risks like inadequate staffing, irregular shifts, low job control and decision latitude, job insecurity, inadequate training and unclear reporting procedures can impact the likelihood of both MSD and workplace violence. Similarly, stress, burnout, low perceived organizational support, poor safety culture and lack of psychological safety are also risks that increase the chance of MSD and workplace violence.

Being aware of the organizational and psychosocial risks mentioned above are key to reducing the likelihood of MSD, workplace violence and the chance that workplace violence could lead to an MSD. More targeted efforts to mitigate workplace violence as a potential risk factor for MSD are offered below.

Conclusion

Workplace violence can be a significant but preventable contributor to MSD. Empirical evidence supports its inclusion as a risk factor and reinforces the need for integrated prevention strategies that address work design, organizational conditions and psychosocial factors. Such integration of workplace violence prevention into MSD frameworks can result in improved risk identification, enhanced intervention effectiveness and overall healthier, safer work systems.

Key messages

  • Workplace violence is an underrecognized MSD risk factor. It can contribute directly through physical strain and indirectly through stress, fatigue, and other health impacts.
  • MSD and workplace violence share common root causes. Factors like staffing, job design, and safety culture influence both, making siloed prevention approaches less effective.
  • Integrated, systems-level prevention is essential. Addressing workplace violence alongside traditional ergonomics can improve MSD risk identification, strengthen interventions, and lead to safer workplaces.

Recommendations for the Prevention of MSD

  • Integrate Violence into MSD Risk Assessment
    • Treat workplace violence as a potential MSD exposure during hazard identification.
    • Incorporate questions about physical and psychological behaviors, harassment and fear of assault into MSD risk assessments and worker surveys.
    • Avoid framing violence solely as an HR or security issue.
  • Strengthen Safety Climate
    • Establish clear, blame-free reporting systems for workplace violence.
    • Ensure timely organizational response following incidents to reduce prolonged stress exposure.
    • Provide access to psychological support services, including employee assistance programs.
    • Demonstrate genuine leadership commitment to safety and psychological health to buffer MSD risk when violence occurs.
  • Use Participatory Ergonomics as an Integrated Tool
    • Participatory ergonomics efforts can surface workplace violence as a potential risk.
    • Worker involvement enables identification of practical, low-cost solutions that reduce both potential violence exposure and MSD risk.
  • Align Workplace Policies and Guidelines
    • MSD prevention guidelines should reference workplace violence as a potential risk factor.
    • Policies aimed at reducing workplace violence should be evaluated for downstream impacts on MSD outcomes.
    • Trainings that include deescalation techniques and security protocols can benefit workplace safety.

References

  1. Bezzina, A., Austin, E., Nguyen, H., & James, C. (2023). Workplace psychosocial factors and their association with musculoskeletal disorders: a systematic review of longitudinal studies. Workplace Health & Safety, 71(12), 578-588.
  2. Gallagher, S., & Barbe, M. F. (2022). Musculoskeletal Disorders: The Fatigue Failure Mechanism. John Wiley & Sons.
  3. Kang, K. K., Ciminero, M. L., Parry, J. A., & Mauffrey, C. (2021). The psychological effects of musculoskeletal trauma. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 29(7), e322-e329.
  4. Melin, B., & Lundberg, U. (1997). A biopsychosocial approach to work-stress and musculoskeletal disorders. Journal of Psychophysiology, 11(3), 238–247.
  5. Miranda, H., Punnett, L., Gore, R., & Boyer, J. (2011). Violence at the workplace increases the risk of musculoskeletal pain among nursing home workers. Occupational and Environmental Medicine, 68(1), 52–57.
  6. MSD Solutions Lab. (2024). Accounting for non-physical risk factors in MSD prevention. National Safety Council. https://www.nsc.org/getmedia/0044e6ca-3075-4473-b9c6-905d94f62cdf/msd-nonphysical-risk-factor-wp.pdf
  7. Oakman, J., Macdonald, W. A., Mccredie, K., & Clune, S. (2025). Impact of work-related psychosocial versus biomechanical hazards on risk of musculoskeletal disorders: A systematic review and meta-analysis. Applied Ergonomics, 125, 104481.
  8. Shockey, T., Alterman, T., Yang, H.O., & Lu, M.L. (2024). Workplace Psychosocial Factors, Work Organization, and Physical Exertion as Risk Factors for Low Back Pain Among US Workers. Journal of Occupational and Environmental Medicine, 66(6), 467-474.
  9. Work to Zero. (2022). Workplace Violence: Using Technology to Reduce Risk. National Safety Council. https://www.nsc.org/faforms/work-to-zero-workplace-violence-white-paper
  10. Yang, H., Haldeman, S., Lu, M.L., & Baker, D. (2016). Low Back Pain Prevalence and Related Workplace Psychosocial Risk Factors: A Study Using Data From the 2010 National Health Interview Survey. J Manipulative Physiol Ther, 39(7), 459-472.
  11. Yang, H., Lu, M.L., Haldeman, S., & Swanson, N. (2023). Psychosocial risk factors for low back pain in US workers: Data from the 2002-2018 quality of work life survey. Am J Ind Med, 66(1), 41-53.

Last updated: 2026

Disclaimer: Position papers are funded by the Centre of Research Expertise for the Prevention of Musculoskeletal Disorders, which receives funding through a grant provided by the Ontario Ministry of Labour, Immigration, Training and Skills Development. The views expressed are those of the authors and do not necessarily reflect those of the Centre nor of the Province.