Perspectives of North American firefighters on navigating interventions and healthcare choices for work-related shoulder disorders

Abstract

Background

The unpredictable nature of firefighting, characterized by lifting and carrying of heavy equipment, forceful upper body movements in confined spaces, and exposure to extreme conditions, predisposes firefighters (FFs) to a range of work-related shoulder disorders (WSDs). The unique occupational demand of firefighting underscores the need for targeted intervention and occupational health programs tailored to the demands of firefighting.

Objective

To explore the: (1) Management strategies that FFs employ after WSDs (2) Needs and preferences of FFs with WSDs in relation to their occupational health and recovery.

Methods

Using an interpretive descriptive methodology, we interviewed 14 firefighters (males, n = 9; females, n = 5) with an average age of 47 years, who experienced WSDs in their careers. Semi-structured one-on-one virtual interviews were conducted using online video conference software and were transcribed verbatim. Data was analyzed using thematic analysis.

Result

Four themes emerged from firefighters as management strategies following WSDs: (1) Appropriate diagnostic precision and tailored management; (2) The critical role of early medical and physiotherapy intervention; (3) Comprehensive social support systems; (4) Adaptive coping mechanisms. Two themes also emerged as needs and preferences in relation to their occupational health and recovery: (1) Formal and targeted training exercise programs; (2) Mandatory health and wellness monitoring programs.

Conclusion

The unique occupational demands of firefighting necessitate a multifaceted and holistic approach to shoulder injury management and prevention. This approach encourages the development of tailored intervention programs that address the specific challenges and perceived needs of firefighters with WSDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12982-025-00739-8.

Introduction

Most of the stabilization for the shoulder is provided by the glenoid labrum, rotator cuff muscles, and glenohumeral ligaments [1] nevertheless, these structures are prone to age-related natural deterioration and/or work-related injuries from strenuous occupations like firefighting [1, 2]. Firefighting is a physically demanding job that requires a high level of fitness and the ability to perform a wide range of tasks [3, 4]. The physical workload of firefighting varies depending on the specific task being performed, such as advancing a charged hose, lifting and carrying heavy equipment or overhaul operations [5, 6]. These strenuous activities, combined with about 20–34 kg of heavy protective gear and tools used to carry out each task inherently increase the risk of developing work-related shoulder disorders (WSDs) [1, 7].

Work-related factors, particularly in high-risk occupations such as firefighting, are well documented contributors to WSDs [1, 8, 9]. A systematic review from 2010 identified key risk factors with a causal association to WSDs, including heavy physical demands, repetitive tasks, and psychosocial work demands such as high levels of stress and limited job control [10]. These risk factors are particularly relevant in firefighting, where duties often involve significant physical exertion [3, 11], exposure to occupational stress [12], and other psychosocial challenges [13, 14].

Work-related shoulder disorders were found to be the third most frequent musculoskeletal injury experienced among firefighters (FFs), costing more than $76,000CAD per injury in Canada [15, 16]. Given the critical role of FFs in emergency response, any reduction in physical capability due to WSDs can have severe implications for the individual while also impacting the effectiveness of the firefighting team. Despite the physical and financial burden of WSDs, there is a notable gap in FFs experiences regarding their preference to management, rehabilitation and prevention of WSDs. Several studies have reported the significance of early management of WSDs and how it positively impacts recovery times and prevents lost time at work [38, 39]. However, existing studies often focus broadly on the injuries, and the unique occupational demands FFs face [17–19]. Moreover, while some general health programs have been recommended in the literature [20–23], there is still a lack of tailored intervention strategies for WSDs that account for the specific demands of firefighting work and the associated risks. Further, social support plays a crucial role in influencing both the physical and mental health of FFs by acting as a buffer against stress and mental health issues, such as depression and post-traumatic stress disorder (PTSD) [24, 25], which are prevalent among high-risk professions like firefighting [26]. However, there has been limited research on the influence of social support on the musculoskeletal health and recovery of FFs. This study aims to bridge these gaps by (1) exploring the management strategies employed by FFs following WSDs and (2) assessing the needs and preferences of FFs in relation to their occupational health and recovery. By focusing on these areas, our research seeks to provide insights into effective approaches FFs utilize for addressing and navigating tailored interventions following WSDs. The outcomes of this research could guide the development of targeted interventions and occupational health programs that are specifically designed to meet the unique challenges of FFs with WSDs. Hence, supporting their well-being and maintaining their readiness in responding to emergencies.

Methods

Study design

Interpretive description (ID) was employed for this qualitative study as it integrates multiple conventional qualitative methods of inquiry and provides a thorough and contextual understanding of the phenomena of interest using a variety of data collection techniques [27, 28] Interpretive description gives a deeper understanding of participant perspective while recognizing variation in perceptions. It enables clinical researchers to develop a better understanding of the subjective reality of a population of interest. Interpretive description allows researchers to answer clinical questions across the healthcare sciences with theoretical integrity. As such, ID was chosen to develop knowledge that enhances clinical practice about the health and wellbeing of FFs [28, 29]. The constructivist paradigm was also utilized as it is particularly effective for investigating complex, experience-driven questions, especially in applied domains like healthcare, where uncovering participants’ meanings and contextual nuances is crucial for deriving actionable insights. Within this paradigm, researchers actively engage in the process of knowledge generation and co-creation with study participants.

Eligibility and recruitment of participants

We recruited participants from September 26th, 2023, to June 25th, 2024, using various strategies including advertisement in firefighter organizations, websites, unions, and networks, such as the Canadian Association of Fire Chiefs (CAFC) and FIREWELL, social media platforms like Facebook, X, and LinkedIn.

We employed purposive sampling, specifically criterion-based [30], to target a range of participants from career and volunteer FFs, including front-line FFs, firefighter-paramedic and fire chiefs. Eligible FFs, who had a minimum of one year of work experience, were 18 years or older, spoke English, and had experienced WSDs while on active duty. These participants were identified after completing a screening questionnaire to assess their eligibility for recruitment. To ensure diversity, we also used maximum variation sampling of participants from various geographical locations to reflect different community types and roles. Additionally, we made sure to adequately include female FFs, and gender or ethnic minorities in our study. The sample size was continually assessed to determine when data sufficiency was reached, allowing us to capture the full complexity of our research objectives [27, 31].

Data collection, methods and procedures

To facilitate the co-construction of the phenomena of interest, participants were allowed to choose their preferred interview format: online via Zoom, telephone, or in-person but regardless, all participants were interviewed by the first author (TO) via Zoom. Written and verbally informed consent was also received prior to the start of the semi-structured interview process at participants’ convenience. Then, we conducted an in-depth interview with each session lasting approximately 30 min to 1 h. The interview guide was developed based on the researchers’ empirical experiences and existing literature [32]. (see Appendix 1).

The interview guide helped to provide structure during the semi-structured interviews while allowing the researcher to explore crucial information and intriguing statements relevant to the objective of the study. Similarly, the semi-structured interviews with FFs provided detailed insights of their preferred management procedures including their needs and preferences in relation to their occupational health and recovery. Throughout the data collection, we revised the interview guide as our knowledge and insights evolved. This was achieved through collaborative team discussions with researchers who have several years of experience in firefighter and musculoskeletal health research. The data collection process was iterative, with each data collection process building on the knowledge gained from the previous semi-structured interviews.

Data analysis

All data were anonymized during the semi-structured interviews and transferred to NVivo 14 software. The software primarily served to sort and organize the data to enhance transparency, and the analysis was conducted simultaneously with data collection. Using the ID approach, patterns or themes were identified, examined, and described using thematic analysis and inductive coding. We specifically adhered to the six stages of thematic analysis proposed by Braun and Clarke, which include immersing oneself with the data, creating preliminary codes, looking for themes, evaluating themes, defining and labeling themes, and creating the report [33]. Reflexive journals and memos were also employed to examine the researchers’ personal and professional assumptions as well as their ontological views to guide the analytical process [28].

Firstly, we immersed ourselves in the data to grasp the broader context beyond initial impressions. The researcher (TO) conducted the transcription and data immersion continued through repeated readings of the transcripts to identify significant issues, likely themes, and patterns [29, 34]. Three researchers (TO, DB, and JMD) independently performed a pilot open coding of one transcript to ensure agreement following coding. Disagreements were discussed and resolved within the team to reach a consensus, and the remaining 13 interview transcripts were coded independently by two researchers (TO and DB).

We employed an iterative approach utilizing reflexive notes recorded in a journal during and after each interview to help maintain coherence throughout the analysis of the data [28, 35]. As the analysis continued, our interpretations evolved beyond the initial theoretical framework. For instance, we initially focused on management and healthcare choices following WSDs among FFs. However, as our analysis deepened, we gained a more nuanced understanding of the complexities surrounding various healthcare interventions available or lacking to FFs following their shoulder injury and how these factors influence their recovery.

Major findings

Participants characteristics

We recruited and conducted interviews with 17 participants, but only 14 participants’ data were analyzed (See to Table 1). Despite 17 participants completing the screening and demographic questions, three imposter participants (male = 1; female = 2) were removed from the study after their interviews. The reason for their exclusion was that the questions posed during the interview sessions and their interview responses were inconsistent which prevented their interviews from being analyzed. They pretended to be real FFs to receive incentives but were removed because their views were flawed and to avoid contamination of the data. A significant number of the participants with WSDs reported having rotator cuff and labral tears, while others reported muscle strains and nerve impingement (See Table 1). Majority of the participants reported symptoms of pain and reduced range of motion in the affected shoulder. The participants’ average age was 47 years and the average tenure as FFs was 18 years. Lastly, most participants were Caucasians (n = 13), and our sample reported only one of each gender (n = 1) and ethnic (n = 1) minority.

Table 1.

Firefighters demographic characteristics

ID	Participants demographics	Shoulder disorders (affected shoulder)	Pain level /10	Work context & years of service
FF01	Age: 63, Male, USA	Muscle injury, nerve impingement (Left side)	8	Career firefighter, 32 years
FF03	Age: 55, Male, USA	RCT (Right side)	7	Career firefighter, 33 years
FF05	Age: 51, Male, USA	RCT & labral tear (Right side)	10	Career firefighter, 32 years
FF06	Age: 42, Male, Canada	RCT (Left side)	7	Volunteer & career firefighter, 10 years
FFP07	Age: 35, Female, USA	Labral tear (Right side)	Not specified	Career firefighter-paramedic, 6 years
FF08	Age: 44, Male, USA	Compression injury (RCT) (Left side)	7	Career firefighter, 22 years
FF09	Age: 26, Male, USA	Mild shoulder muscle strain (Right side)	6	Volunteer & career firefighter, 9 years
FF11	Age: 30, Male, Canada	Subscapularis tear (Right side)	5	Career firefighter, 5 years
FF12	Age: 44, Male, Canada	Bicep tendinopathy (Left side)	7	Career firefighter, 21 years
FF13	Age: 55, Female, Canada	Frozen shoulder (Right side)	8.5	Career firefighter, 6 years
FF14	Age: 51, Female, Canada	Muscle strain & labral tear (Right side)	8	Career firefighter, 27 years
FF15	Age: 52, Female, Canada	Supraspinatus tear (Right side)	Not specified	Career firefighter, 20 years
FF16	Age: 61, Male, Canada	Shoulder separation (Right side)	8	Career firefighter, 27 years
FF17	Age: 46, Female, Canada	Repetitive strain injury (RSI) (Bilateral)	5	Career firefighter, 12 years

RCT rotator-cuff tear; FF firefighter; FFP firefighter-paramedic; WSDS work-related shoulder disorders

Major themes

After reviewing extracted codes, final themes were repeatedly revised by the research team through an iterative process of discussions (See Fig. 1). Four themes emerged as management strategies following WSDs: (1) Appropriate diagnostic precision and tailored management; (2) The critical role of early medical and physiotherapy intervention; (3) Comprehensive social support systems; and (4) Adaptive coping mechanisms. Two themes also emerged as needs and preferences in relation to their occupational health and recovery: (5) Formal and targeted training exercise programs; and (6) Mandatory health and wellness monitoring programs.

Fig. 1.

Conceptual model of management strategies, needs and preferences of firefighters with WSDs

Management strategies

Theme 1: appropriate diagnostic precision and tailored management

Many FFs reported that their first step in understanding the type and severity of their shoulder injury was using various diagnostic tools including x-rays, ultrasounds, and Magnetic Resonance Imaging (MRI). Firefighters explained that diagnostic assessments allow for the accurate identification of the type and extent of a shoulder injury, whether muscle strain, rotator cuff tear, or tendinosis.

“…So, I went to be evaluated, the doctor did some X-rays, nothing was broken and so, we just treated it like a trauma, a deep bruise or strain to my right shoulder and couple weeks went by, it never got any better and so he requested an MRI which showed damage to one of the joints on the very top of my shoulder near the rotator cuff, that it was compressed”. FF08, Male, RCT.

Another firefighter reported that: “…My MRI revealed tears in my subscapularis and bone marrow edema at the site of impact from the original injury…” FF11, Male, Subscapularis tear.

Firefighters also noted that the result of their diagnostic assessment helped medical practitioners dictate the next course of treatment including physiotherapy, medication, or a need for referral to an orthopedic surgeon for further management. This specificity was said to be crucial to them and their healthcare providers in helping them tailor the treatment to their shoulder injury, which can significantly impact recovery times and outcomes.

“…We had the MRI, and they saw exactly what was happening, that my courses of action were to be very disciplined with physical therapy both prior to and post-surgery…” FF03, Male, RCT.

Another firefighter noted that: “…I went to see my family doctor who ordered me to get an ultrasound to check on the extent of the injury as well as an MRI to diagnostically assess the injury and then at that time my family doctor suggested that I consult a physiotherapist …” FF17, Female, RSI.

Theme 2: the critical role of early medical and physiotherapy intervention

Firefighters acknowledged that initiating treatment at the first sign or symptom can prevent worsening of the shoulder injury that could arise due to lack of immediate medical or physiotherapy attention. Early intervention was believed by most FFs to help stabilize their shoulder injury, reduce inflammation, and prevent further complications that could arise from neglect. This was especially important for FFs who often engage in activities that could exacerbate existing injuries, such as lifting heavy equipment or performing rescue operations. Firefighters who initiated early interventions soon after their shoulder injury reported reduced recovery time and prompt return to work after the WSDs.

“…I was able to get in to see an orthopedic surgeon maybe the day after the extreme arm pain began and we got MRI imaging right away with an arthroscopy where they inject dye into your joints and it was noted that I had a labral tear that went from anterior to posterior, so like a 180 degrees and that I would likely need surgery, so we scheduled it right away and because I didn’t want to mess around and I knew that waiting was going to possibly loosen the joint capsule, and I would end up with further injuries, tearing my rotator cuff as well, so we opted to go the surgery route and fixed it right away so that I could get back to work sooner and off light duty…” FFP07, Female, Labral Tear.

In contrast, other FFs who acknowledged delayed management of their shoulder injuries often reported worsening of the condition and even chronic complications including increased pain, reduced function, and prolonged recovery time.

“It started gradually, so I didn’t think it needed immediate attention. But over time, it kept coming back and getting worse because I didn’t get it treated early enough.” FF17, Female, RSI.

Another added that: “I didn’t think it was that serious at first, so I just pushed through the pain. But over time, it got worse, and by the time I saw a doctor, I had already done more damage than if I’d stopped earlier.” FF01, Male, Nerve Impingement.

Additionally, FFs reported that wait times for non-urgent healthcare services, including specialist consultations and diagnostic imaging, can be prolonged. This delay may hinder timely treatment, prolonging recovery and increasing the risk of long-term disability. One participant highlighted this challenge, stating: “It took me almost four months to get the MRI approved and by then, the pain had worsened, and my range of motion was severely impacted. I feel like if they had acted quicker, it wouldn’t have gotten this bad.” FF06, Male, RCT.

Another firefighter added that: “We are covered for some things, but it takes time to get the imaging or the therapy, especially for non-urgent (shoulder) injuries.” FF12, Male, Bicep Tendinopathy.

Sub-theme 2.1: Treatment seeking behavior of firefighters with shoulder injury: Firefighters’ perception of the implications of shoulder injuries on their career can significantly impact a firefighter’s decision to seek medical treatment. The concern about being sidelined, potential loss of income, or even the impact on long-term career prospects can make FFs hesitant to address a shoulder injury until it becomes unavoidable or affects their ability to work. In certain cases, how FFs perceive their shoulder injury, whether as a minor inconvenience or a serious health concern significantly influences their willingness to seek medical intervention.

“…when I first started feeling it (shoulder pain), I remember contributing it to oh it’s probably just my workout. My shoulders are sore from my workout, that’s all, and then it just didn’t go away. So, I thought, oh, maybe I strained my shoulder. So, I left it, I was icing it. I was taking some pain meds, and I was just letting it heal because I’m used to injuries, …but then it would just continuously creep up on me whenever I engage my shoulders in any meaningful activities at work… I was icing it a lot, I was putting heat pads on it, and nothing seemed to work. And then it progressed to just slowly get worse and worse…” FF06, Male, RCT.

The immediate or initial impact of the injury on their ability to perform job duties and everyday activities can influence the perceived severity of the WSDs. An injury that significantly hampers firefighters’ ability to work or affects their quality of life is more likely to be seen as severe and worthy of medical intervention. This perceived self-assessment, and potential denial can lead to delays in seeking medical treatment.

“…there’s a lot of people that still come to work with minor (shoulder) injuries because it’s not, you know what I mean? It’s not a big deal.” FF06, Male, RCT.

Another claimed that: “I kept putting off going to get it checked because it seemed manageable, but eventually, it reached a point where I couldn’t ignore it anymore. By that time, I had torn something that could have been avoided if I’d addressed it earlier.” FF08, Male, RCT.

Sub-theme 2.2: Variability in treatment choices and recovery strategies: Each firefighter’s management strategy was noted to be unique and dependent on the nature and severity of WSDs, overall health, job requirements, and personal preferences. For instance, many FFs who reported rotator cuffs tears, or labral tears of the shoulder were often being referred for surgical interventions as the next course of action after diagnostic assessments and clinical evaluations.

“So, after the MRI, the doctor determined surgery was probably needed in which case I had the surgery. They decompressed the shoulder joint, and then I was on what we call light duty.” FF08, Male, RCT.

Following the surgical procedure most FFs were referred to physiotherapy for further rehabilitation programs prior to discharge by their physicians. However, depending on the type and severity of the shoulder injury, some FFs acknowledged that they personally sought out physiotherapy management without consulting their physicians or undergoing surgical intervention due to their personal preferences or beliefs.

“I didn’t seek out a physician. I went directly to, you know, our benefits allow us to have extensive physical therapy. And I’m a firm believer in physical therapy. So, I sought out physical therapy to treat the (shoulder) injury…” FF12, Male, Bicep Tendinopathy.

Theme 3: comprehensive social support systems

Sub-Theme 3.1: Workplace modifications and accommodations: Firefighters acknowledged that accommodation from their organization was mostly through temporary workplace modifications including light duties to avoid tasks that exacerbate the shoulder condition. In addition, FFs recounted that some accommodations or adjustments were made to fit their work environment by the management while others stated that their union was understanding regarding their work limitations following their shoulder injury. For instance, some FFs reported being pulled off frontline firefighting tasks and were assigned modified light duties such as training of new recruits or desk duty, which involves minimal engagement of the affected shoulder.

“…you’ll go on what we call light duty, which is basically they’ll put you somewhere within the department logistics and there you’ll answer phones or do something that you can do with your injury until you’re cleared to go back to the truck.” FF09, Male, Muscle Strain.

Another firefighter noted that: “…In terms of my actual workplace, I mean they’re very accommodating in terms of modified duties and making sure when I come back to work, I can do the proper exercises I need to, throughout the day and take breaks and ice my shoulder if I need to so, yeah, they’ve been very good that way.” FF11, Male, Subscapularis Tear.

Sub-Theme 3.2: Organizational support: Most firefighters reported varying levels of organizational support. For instance, a female firefighter stated that during her recovery, her organization provided both financial and emotional support including paid sick leave, more time off work for treatment, or rehabilitation appointments. Further, she added that the organization did some personal home visits outside of work which were very helpful for recovery after the shoulder injury. “I would say that my union to a small degree did some sort of check-ins, the organization supported me in the fact that they allowed me to be on you know, a paid leave in terms of rehabbing and sort of regular check-ins in accordance with our sort of medical leave policy. I was lucky because we have a good health plan as a career firefighter that allowed me to get good quality care…” FF13, Female, Frozen Shoulder.

Another firefighter echoed this: “We have a policy in place that speaks to rehab (shoulder) just meaning if we’ve been working for an extended period of time, we need a certain amount of time break before we get reassigned. I think that’s kind of really the only thing we have in place.” FF11, Male, Subscapularis Tear.

Other firefighters reported having an accessible healthcare specialist or fitness coach within the department for annual checkups to help with any health-related concerns. These fire departments created awareness and health care resources about WSDs among their staff members to prevent further complications among FFs.

“We have an occupational health clinic that is specific for the police department and the fire department, and about two months ago, I reached out to them to have them assemble educational information on shoulder injury prevention because of the number of shoulder injuries we were seeing…” FF05, Male, Labral Tear & RCT.

Other FFs claimed that: “We have a fitness coordinator that can do like dietitian-like healthy eating programs for us. And he can by request design workout programs that fit a lot of the tasks that we do. Yeah, it’s not required to talk to him, but he’s a phone call or e-mail away and you let him know what you’re trying to accomplish, whether it be just to stay in shape or strengthen the damaged shoulder in this scenario, and he’s certified to write up a program. FF08, Male, RCT.

Sub-Theme 3.3: Peer and family support: In relation to peer support, FFs with WSDs mentioned that they sometimes rely on support from other team members within the organization in carrying out certain tasks that might require maximal effort.

“I needed to rely on my coworkers a little bit more. But I’m also one of those people that’s not too proud to recognize that I have a limitation” FF05, Male, Labral Tear & RCT.

Further, support from peers was sometimes extended beyond the workplace which was noted as helpful in the process of recovery.

“Yeah, I know they’ve (peers) been great. I’ve a lot of close friends that I work with, so they all reached out and offered assistance with, you know, things around the house if I needed and even just checking in on, you know, the mental aspect of getting hurt at work and not being able to come back, checking in and touching base and just kind of maintaining that friendship away from the job” FF11, Male, Subscapularis Tear.

Conversely, a female firefighter recounted how the lack of peer support led to a form of isolation that impacted recovery following her shoulder injury.

“…this might be a little bit over sharing, so I also am on our department’s peer support team and so it was pretty eye opening for me to be on light duty and recognize the amount of isolation that occurs and so now, it’s something that will be more closely paid attention to, so all of our employees that are on light duty and those who are secluded and sequestered to make sure that we reach out to them and keep them a part of their community…” FFP07, Female, Labral Tear.

Lastly, FFs believed that family members helped in their recovery process following WSDs. Most FFs who had partners in the home reported varying support received by their partner during management and recovery from their shoulder injuries. For instance, they reported emotional and physical assistance from family members, including help with daily tasks that became challenging and moral support during the management and recovery phase of their injury.

“…Well, you know my wife just that she was aware of it (shoulder injury), so she would take over the kids and I kind of learned to live around that…” FF06, Male, RCT.

Another firefighter noted that: “Oh, yeah, yeah. My husband stepped up and took care of things where I struggled” FF15, Female, Supraspinatus Tear.

Theme 4: adaptive coping mechanisms

Firefighters recounted that they often adjusted their daily activities both at work and home to avoid aggravating their shoulder injury. These adjustments involved altering the usual way they perform certain tasks or avoiding certain physical activities that put additional strain on their injured shoulder. For example, some FFs intentionally adjusted how they were donning or doffing their personal protective equipment (PPE) and self-contained breathing apparatus (SCBA) packs at work to avoid triggering the shoulder pain.

“It was difficult, reaching behind, so I generally will change the way that I do it, so I generally will put my right side (affected) on first and then my left side because the left side I can reach behind me better. Whereas in the past I would do it just habitually, would have done it the opposite way, so I have to do things differently now just to make sure I don’t irritate it, and that’s the same with the SCBA”. FF14, Female, Labral Tear.

Some FFs claimed that they often modify their fitness routines to avoid exercises that strain the injured shoulder. This may include focusing on lower-body exercises, using lighter weights, and incorporating more cardio activities to maintain overall fitness.

“…I did more overhead weight training (prior to the shoulder injury) and that involved moving a weight from the ground to over my head in one motion. It’s like Olympic weightlifting, and now I can’t really do that movement anymore. So, I’ve shifted to doing either a movement that involves moving weight from the floor to shoulder level and then from shoulder to overhead to interrupt the movement a bit. It requires less mobility, and I’ve reduced the weight in those activities and overall, I just do that kind of weightlifting less…” FF17, Female, RSI.

Another firefighter claimed that: “…I modify whatever the exercise is, I would never do an overhead shoulder presses, those kinds of things, and often I tend to do a little bit more cardio than I would do weightlifting at work just because it’s easier on my body…” FF14, Female, Muscle Strain & Labral Tear.

In contrast, another group of FFs noted that they utilized over-the-counter pain relievers to manage pain and inflammation, including non-prescription medications such as ibuprofen or acetaminophen, while claiming to follow appropriate pharmaceutical guidelines to avoid any adverse effects of the medications. However, a firefighter explained that in an extreme case of shoulder pain he would use stronger medications or marijuana to help him sleep and manage the excruciating shoulder pain.

“… I took a lot of extra-strength Aleve I pretty much lived off that stuff from Costco 100% and weed so yeah…I wasn’t like taking excessive amounts of it (Aleve), but I would know when they’re about to wear off. Like I just take two in the morning, two at lunch and two in the evening and I’m usually pretty good, but I found I had to take a lot of Aleve. Well, you know, six pills a day otherwise I couldn’t, I would never be able to survive…” FF06, Male, RCT.

Another firefighter added that: “I think around the time I was registering a 8.5 (shoulder pain level) to the point when…, I was probably averaging daily about a six (pills) managing with ibuprofen and like I say compensating…” FF13, Female, Frozen shoulder.

A final group of FFs reported that coping as an intervention strategy for recovery meant being more aware of their shoulder injury and learning to live with it. These FFs believed that it was part of the job, and some injuries are usually unavoidable, so they have learned to accept the reality of experiencing the injury while also going about their firefighting tasks despite the WSDs.

“I was a lot more aware of not using my shoulder if I didn’t have to and using a different part of my body to do different tasks if I could, which might not have been the most effective way, but I was just trying to work through an injury (shoulder). But yeah, the job, the job is very physically demanding, and you need to be able to use every part of your body to the best of your ability.” FF11, Male, Subscapularis Tear.

Furthermore, these FFs noted that they sometimes avoid using the affected shoulder in completing their activities of daily living and this often works especially if the affected shoulder is the non-dominant extremity.

“…So, I just avoid using it (shoulder) a lot and I’m able to, you know like my left arm is not my primary arm, right. So, this would be a lot more difficult than with my right arm because I’m right-handed, but because it’s my left arm (affected), I get away with a lot because I don’t need to use my left arm a lot except for stabilizing. So, for me I just have coped with it by using my right arm a lot more…” FF06, Male, RCT.

Another firefighter noted that they would sometimes compensate or substitute the injured shoulder with other functional parts of their bodies if they found it difficult to use the affected dominant extremity.

“I just end up compensating if I could do it with my right arm (affected), I would and if I couldn’t, I would have to switch to my left arm and I should mention that my right side is my dominant arm. So, writing left-handed and eating left-handed and brushing your teeth and walking the dog, it’s a lot more than you realize until you get into it.” FFP07, Female, Labral Tear.

Needs and preferences of firefighters with work-related shoulder disorders

Theme 5: formal and targeted training exercise programs

Firefighters stated that most of their work-related exercise training programs were not targeted to their specific needs and increased their risk of WSDs. They claimed that their exercise routines at work were optional and non-specific, they also believed that their personal routine exercises did not provide the tailored strength, flexibility, and endurance training that firefighters require to perform their duties safely and effectively.

“We’re not mandated, we are provided with exercise equipment, but it’s not mandatory, no.” FF11, Male, Subscapularis Tear.

Another firefighter added that although they are provided with this exercise equipment in the stations, there is a lack of awareness or training on how to do safe and targeted exercises based on individuality or personal needs.

“…We actually have a physical fitness policy that says that we are to do a minimum of one hour of a physical fitness training, but it doesn’t specify what to do. It doesn’t say you have to run these days or lift weights this day, but it just it says some form of physical fitness…” FF08, Male, RCT.

Firefighters further stated that training exercises that did not simulate their fire-ground tasks can result in reduced operational effectiveness and higher susceptibility to acute and chronic WRMSDs including WSDs. Firefighters reported that they would prefer a more formal, balanced, and diverse exercise training program that is continuous, functional and simulates their firefighting tasks.

“…So, I would say that, you know, look at training, like creating training regimes that are balanced and diverse so that you can recreate diversity of movement rather than sort of like constantly just arm curls or, you know bench presses, right?” FF13, Female, Frozen Shoulder.

Firefighters further emphasized that there are some underlining deficiencies in their current training exercise programs. They claimed that most of their programs focused on strength training and did not incorporate joint mobility and flexibility exercises, which are important for preventing injuries and enhancing their overall physical resilience.

“I think we as firefighters draw a lot on strength training but not on mobility and flexibility for the joints. I think maybe that’s a deficiency that could be addressed… I think that we’re missing that flexibility and mobility, which helps with the joints, and I think that’s a piece that I think we can take on, in a little bit better fashion than we are right now…” FF03, Male, RCT.

Theme 6: mandatory health and wellness monitoring program

A mandatory health and wellness monitoring program for FFs was reported to be crucial because it ensures consistent and proactive management of their physical and mental health. Regular health screenings were noted to help promote the early detection of underlying health related issues that are significantly impacted by the demands of their job.

“…If management doesn’t have things in place such as maintaining our physical fitness. You know, regular physicals examinations by doctors, things like that. If they don’t have that in place, in writing, in a policy manual, I feel like you will have some firefighters that do absolutely nothing unless the call hits.” FF08, Male, RCT.

Other firefighters emphasized that having structured programs within their organization helped to improve their physical capabilities while at work and minimized the risk of having a shoulder injury while performing their firefighting duties.

“Where I worked was a fire and EMS industrial complex. We were required to work out one hour each day when we were on shift, which helped immensely in our physical capacities. So that was one of our job requirements.” FF17, Female, RSI.

Further, some FFs expressed that increased medical monitoring is necessary and long overdue for FFs. They stressed that the legislative integration of mandatory health and monitoring programs for FFs might prove beneficial at minimizing WSDs and help to improve their health and well-being.

“…Well, I know the legislation is coming down the pipe for more medical monitoring and in my opinion, it’s a long time. I can’t remember the bill. I can’t remember the number of the bill, but it’s coming that it’s going to become mandatory that we have medical monitoring and as long as it’s non punitive, I think it’ll be a step in the right direction…” FF12, Male, Bicep Tendinopathy.

Discussion

The findings of our study illuminate the need for specialized management and prevention strategies tailored to the unique demands of firefighting. Four primary themes emerged in relation to the management strategies employed by FFs after experiencing WSDs including diagnostic precision and tailored management, early medical and physiotherapy intervention, comprehensive social support systems, and adaptive coping mechanisms. Two themes related to the needs and preferences of healthcare choices emerged including formal and targeted training exercise programs and the need for mandatory health and wellness monitoring programs.

The emphasis on precise diagnostic tools as an initial step in management of WSDs underscores the necessity for accurate and prompt diagnosis, which helps determine the most effective treatment strategies. These narratives also highlight how accurate diagnosis is essential for devising customized treatment plans that cater to the unique requirements of each shoulder injury, thereby optimizing recovery outcomes and minimizing recovery times. Evidence has shown the critical role of diagnostic tools like ultrasound and MRIs in identifying the extent and specific characteristics of musculoskeletal injuries for better-targeted treatment [36, 37].

However, other studies have also emphasized that the severity of symptoms does not always correlate with the use of diagnostic tools alone but a combination of other clinical findings [38, 39]. This aligns with findings from our study which reported the importance of an initial accurate clinical diagnosis and a step-by-step treatment protocol to achieve good outcomes and reduce re-injury rates among FFs with WSDs. This theme also reflects the intersection of medical technology and personalized healthcare in addressing occupational injuries in high-risk professions like firefighting.

The importance of timely medical and physiotherapy intervention cannot be overstated, as early and appropriate management is helpful for achieving successful recovery outcomes [41, 42]. Research shows that focusing on immediate treatment and rehabilitation using standardized treatment based on current evidence-based practice and occupational factors, can better help to tailor interventions to a target population [36, 40]. In contrast, the lack of early medical intervention especially in adverse work settings like firefighting and the non-compliance with intervention or rehabilitation recommendations can impede the successful rehabilitation of WSDs among FFs [40]. Moreso, when seeking medical or physiotherapy interventions, our study noted differences between American and Canadian FFs. Most career FFs from the USA reported timely diagnosis and management with less wait time compared to their Canadian counterparts which also impacted their recovery time. This might be due to the different healthcare models operated in both countries, Canadian FFs may encounter delays due to the universal nature of the healthcare system, while U.S. FFs may face healthcare access disparities rooted in the variability of insurance and employment models of being either a career or volunteer firefighter. Addressing these systemic gaps might require targeted policy reforms and investments in firefighter-specific health programs to reduce intervention wait times and ensure timely recovery and return to duty.

Furthermore, our findings showed that physiotherapy management was the most cited primary intervention reported by FFs with non-traumatic or a less severe form of WSDs. This aligns with the findings of Brown et al. [41]. , who demonstrated that physiotherapy serves as the main treatment for most non-traumatic WSDs. This approach is particularly effective in managing repetitive overload injuries commonly encountered in occupational settings like firefighting [41]. Notably, previous research has indicated that FFs feel that many health care professionals are not sufficiently aware of the implications of firefighting job demands when establishing healthcare plans or return to work [42].

Similarly, our findings showed that FFs with major traumatic or severe form of WSDs were also referred for physiotherapy management following surgical interventions [37].This suggests that appropriate intervention for WSDs among FFs is often multifaceted and dependent on various factors including the type of WSDs, severity of the WSDs, occupational demands, work settings and personal preferences. Notably, our sub-theme captures the varied personal and professional considerations that influence treatment choices, underlining the importance of customized medical strategies in enhancing functional outcomes for FFs who frequently face physically demanding tasks.

Treatment seeking behavior among FFs with WSDs focuses on how firefighters’ concerns about the implications of shoulder injuries on their careers influence their decisions regarding medical intervention. It captures the tension between the immediate need to address health issues and the potential consequences on job security, income, and long-term career aspirations. These narratives reveal that the initial minimization of symptoms as mere consequences of routine physical exertion can lead to a delay in seeking appropriate care. This sub-theme also explores the notion that the perceived severity of the injury, shaped by its impact on job performance and daily activities, can shift a firefighter’s willingness to seek timely medical attention, thus impacting recovery and health outcomes. This aligns with a study in the United States which showed that 314 cohort of FFs were reluctant to report a work-related musculoskeletal injury including WSDs due to fear of jeopardizing future career opportunities (40%) or being placed on light duty (45.9%) with more than 53% of this cohort accepting their pain as a natural part of the job [7]. These perspectives showed the structural, psychological and cultural barriers FFs face in acknowledging the seriousness of their shoulder injuries, which in turn can exacerbate the condition and complicate recovery processes.

Social support systems play a crucial role in the management and recovery from WSDs among FFs. Social support can come from various sources, including colleagues, family, friends, and professional healthcare teams. The importance of social support as highlighted by firefighters in our study agrees with another study indicating that peers, family and organizational support systems are vital in recovery process [43]. Studies have shown that social support has been a significant factor in facilitating better health outcomes and recovery following musculoskeletal injuries [44, 45]. Conversely, the perceived lack of social support in patients with musculoskeletal injuries like WSDs has been associated with mental health disorders including post-traumatic stress disorders [43, 46]. Our study emphasizes the critical role of varying levels of comprehensive social support in recovery and early return to work among FFs following a shoulder injury. This aligns with other studies in literature that show that social support aids in practical recovery steps such as rehabilitation exercises, modifications of work duties and early return to work [45, 47].

Adaptive coping mechanisms were noted by FFs to be beneficial at various stages of their recovery following a shoulder injury. This theme captures analgesic and substance use among FFs including marijuana and how FFs consciously modify their work routines, fitness regimens, and everyday activities to accommodate and manage their shoulder injuries, to prevent further aggravation. The use of prescribed or non-prescribed over-the-counter analgesics in our study was mostly seen as a temporary or complimentary form of pain relief following their shoulder injury. This agrees with a study that recommended analgesic as a second line of treatment following WSDs [36]. However, substance use such as marijuana, might be a cause for concern among FFs. For instance, a USA study by Carey et al., [48] showed that 20% of FFs are involved in nicotine use which is strongly linked to alcohol consumption, higher stress levels and poor cardiovascular health. In addition, analgesics and substance use may allow for some pain relief and sleep in the short term [36], but over time may cause impaired cognition at work when pharmaceutical guidelines are not followed thereby putting the lives of victims, and other team members at risk. Likewise, the modification of movement to other non-injured body parts as an adaptive coping strategy has been shown to reduce the risk of injuries among FFs [49], but may also lead to secondary injuries and accelerated wear in other joints and muscle groups.

Moreso, adaptive coping strategies that involve modification of everyday routines encompass a range of self-regulatory techniques that either directly address (approach or active strategies) or evade (avoidance or passive strategies) the situation or stressor [50, 51]. Adopting personal coping techniques among FFs within our study included employing avoidance and/or approach strategies. This was essential for managing their pain, maintaining functionality, and ensuring psychological well-being, which was consistent with other studies in literature. For instance, a qualitative focus group study of 22 UK FFs showed that they utilized a problem-focused (a form of active coping) or emotion-focused a form of passive coping) strategy when faced with physical stressors, including the risk of WSDs, to effectively manage the physical demands and challenges encountered during firefighting incidents [52]. Additionally, public safety personnel, including FFs, use self-initiated coping strategies like education, self-reliance, and treatment (also an active form of coping strategy) to manage physical stressors such as WSDs [51]. This suggests that FFs can benefit from coping through self-management training that could be incorporated into their regular training programs to help minimize the risk of shoulder injuries or re-injury. Moreover, this highlights the resilience and adaptability of FFs in managing their shoulder injuries while maintaining their roles and responsibilities.

Firefighters frequently struggle with consistently engaging in exercise, and there is concern about risk of injury due to the physical demands of the job [53]. Targeted training exercise programs were acknowledged by FFs as a potential solution but has been quite inadequate due to the lack of access to specialized exercise training programs similar to their firefighting tasks [43]. Evidence has established the specific risks associated with firefighting [6, 54] and tailored training programs have been continuously recommended to minimize or prevent these WSDs [43, 55, 56]. For example, a systematic review in 2019 by Hoosain et al., [57] aligns with our findings, which suggest that workplace-targeted exercise programs can be an effective approach for managing WSDs. Potential benefits of targeted exercise programs have also been documented, such as reduced time off work, earlier return to work, improved quality of life, and reduced injury costs for both employees and employers [43, 55, 56]. Despite the numerous benefits and consistent recommendation of a targeted and formal exercise program, there is still a lack of access to these exercise routines tailored to the demands of firefighting tasks.

The need for mandatory health and wellness monitoring programs as noted by FFs in our study can help prevent or minimize the risk of occupational injuries such as WSDs as it highlights a proactive approach to occupational health within firefighting organizations. This management strategy aligns with the concept of preventative healthcare in literature, where the focus is not only on treating occupational injuries [53] like WSDs among FFs. However, this may also help in preventing other common modifiable occupational risks specific to FFs through regular physical conditioning and continuous health monitoring [43]. Given the host of occupational health challenges like WSDs peculiar to the job of firefighting, implementing regular and mandatory physical ability testing for FFs to monitor their readiness throughout their careers and intervene is necessary. Furthermore, there has been a lack of compliance to the government guidelines and recommendations for health and wellness among FFs [58]. Specifically, about 10 to 25% of fire departments in the United States have some kind of wellness programs [43]. However, most fire organizations are still lacking a structured health and wellness program, creating a potential gap in determining an “ideal” program for individual fire organizations. Therefore, investing in appropriate medical surveillance and mandatory intervention programs for FFs who are at high risk for health issues cannot be over emphasized.

Conclusion and implications for policy and practice

Our study advocate for a holistic and multifaceted approach to the management and prevention of WSDs among FFs. There is a clear indication that firefighting organizations need to integrate specialized physical training programs, regular health assessments, and robust support systems into their standard operational protocols. Early access to physiotherapists and orthopedic surgeons who are familiar with the demands of firefighting are needed to ensure an accurate diagnosis and treatment that is optimized to the shoulder disorder and the work demands. Implementing these strategies can lead to better health outcomes, reduced incidence of WSDs, and potentially lower healthcare costs associated with occupational injuries. Effective management often requires collaboration between FFs, healthcare professionals, and the fire department to ensure a safe and successful return to duty. Furthermore, the legislative integration of these strategies could improve the overall well-being and operational readiness of firefighters universally. This might enhance their ability to meet the demands of their critical roles in emergency response and may help to inform better policies for firefighter health and wellness initiatives.

Limitations

Our findings were mostly reported by North American male Caucasian FFs and this study may lack sufficient diversity that may influence healthcare experiences, access to services, and perceptions of WSDs management. Our study may not fully capture the nuanced ways in which these intersecting identities impact experiences of FFs with WSDs. Secondly, our findings were based on self-reported data, which may not accurately reflect true behaviors or outcomes due to subjective or recall biases in interpreting the experiences of FFs. Lastly, our findings are context-specific and may not be fully applicable to FFs in different countries or even regions outside North America where healthcare systems, access to resources, and occupational demands may vary. While this study provides rich, in-depth insights, its generalizability to the broader population of FFs might be limited.

Future research recommendations

Future research should aim to explore demographic variations, in the management and recovery of WSDs across various ethnicities, gender, and job roles to include a larger and more diverse cohort of FFs. Further research is also needed to explore the long-term consequences and impact of movement modifications, substance use and self-medications on the job performance of FFs following WSDs. Additionally, longitudinal studies could provide deeper insights into the long-term efficacy of different physical training programs, the varying levels of comprehensive support systems and health monitoring programs in preventing WSDs among FFs. Lastly, investigating the integration of technology and innovation in monitoring and training could offer new insights into more effective management and prevention strategies for FFs with WSDs to yield better solutions for tailoring interventions more effectively.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

Conceptualization, T.O. and J.M.D.; Methodology, T.O. and J.M.D.; Data collection, T.O.; Data analysis, T.O., J.M.D., and D.B.; Figure conceptualization, T.O.; Writing—original draft preparation, T.O.; Writing—reviewing and editing, T.O., J.M.D., D.B., K.F.; Supervision, T.O, J.M.D., P.P., K.F.; Funding acquisition, T.O. and J.M.D. All authors have read and agreed to the submission of the manuscript for publication.

Funding

This research was funded by Canadian Institute of Health Research (CIHR), Code: 202211FBD-493857-92798. Seed grant funding (2024/2025) was also received from the Centre of Research Expertise for the Prevention of Musculoskeletal Disorders (CRE-MSD).

Data availability

Data sets generated during the current study are available from the corresponding author on reasonable request and cannot be shared publicly due to reasons of sensitivity and to protect the privacy of participants.

Declarations

Competing interests

The authors declare no competing interests.

Ethics approval

Our study was approved by the Western Research Ethics Board (HSREB) (Project ID#122676) of Canada. This study was conducted in full compliance with the ethical principles outlined in the Declaration of Helsinki [59].

Consent to participate

The signed informed consent form and verbal consent was received prior to the commencement of the semi-structured interview of participants.