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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsJuly 2013

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19 DE Admin. Code 1342
The Secretary of Labor, in accordance with 19 Del.C. §§2322C, has proposed revisions to the rules and regulations relating to the practice guidelines in the Delaware Workers' Compensation Health Care Payment System (HCPS). These proposals to the PART G Lower Extremity Treatment Guidelines adds the effective date; deletes references to maximum medical improvements; and changes the number of maximum allowable treatments for superficial heat and cold therapy.
Pursuant to 19 Del.C. §2322C, health care practice guidelines have been adopted and recommended by the Health Care Advisory Panel to guide utilization of health care treatments in workers' compensation including, but not limited to, care provided for the treatment of employees by or under the supervision of a licensed health care provider, prescription drug utilization, inpatient hospitalization and length of stay, diagnostic testing, physical therapy, chiropractic care and palliative care. The health care practice guidelines apply to all treatments provided after the effective date of the regulation adopted by the Department of Labor, May 23, 2008, and regardless of the date of injury. Lower Extremity was added to the list of treatment guidelines, effective 6/13/2011. The guidelines are, to the extent permitted by the most current medical science or applicable science, based on well-documented scientific research concerning efficacious treatment for injuries and occupational disease. To the extent that well-documented scientific research regarding the above is not available at the time of adoption of the guidelines, or is not available at the time of any revision to the guidelines, the guidelines have been and will be based upon the best available information concerning national consensus regarding best health care practices in the relevant health care community. The guidelines, to the extent practical and consistent with the Act, address treatment of those physical conditions which occur with the greatest frequency, or which require the most expensive treatments, for work-related injuries based upon currently available Delaware data.
Services rendered by any health care provider certified pursuant to 19 Del.C. §2322D(a) to provide treatment or services for injured employees shall be presumed, in the absence of contrary evidence, to be reasonable and necessary if such treatment or service conforms to the most current version of the Delaware health care practice guidelines.
Services provided by any health care provider that is not certified pursuant to 19 Del.C. §2322D(a) shall not be presumed reasonable and necessary unless such services are pre-authorized by the employer or insurance carrier, subject to the exception set forth in 19 Del.C. §2322D(b).
2.1 EDUCATION of the patient and family, as well as the employer, insurer, policy makers and the community should be the primary emphasis in the treatment of lower extremity pain and disability. Currently, practitioners often think of education last, after medications, manual therapy and surgery. Practitioners must develop and implement an effective strategy and skills to educate patients, employers, insurance systems, policy makers and the community as a whole. An education-based paradigm should always start with inexpensive communication providing reassuring information to the patient. More in-depth education currently exists within a treatment regime employing functional restorative and innovative programs of prevention and rehabilitation. No treatment plan is complete without addressing issues of individual and/or group patient education as a means of facilitating self-management of symptoms and prevention.
2.2 TREATMENT PARAMETER DURATION: Time frames for specific interventions commence once treatments have been initiated, not on the date of injury. Obviously, duration will be impacted by patient compliance, as well as co-morbidities and availability of services. Clinical judgment may substantiate the need to accelerate or decelerate the time frames discussed in this document. Causality of symptoms and dysfunction may occur in a related but different area as a result of the body compensating for the original injury. This scenario is particularly true in the case of lower extremity conditions.
2.3 ACTIVE INTERVENTIONS emphasizing patient responsibility, such as therapeutic exercise and/or functional treatment, are generally emphasized over passive modalities, especially as treatment progresses. Generally, passive interventions are viewed as a means to facilitate progress in an active rehabilitation program with concomitant attainment of objective functional gains. All rehabilitation programs must incorporate “Active Interventions” no later than three weeks after the onset of treatment. Reimbursement for passive modalities only after the first three weeks of treatment without clear evidence of Active Interventions will require supportive documentation.
2.4 ACTIVE THERAPEUTIC EXERCISE PROGRAM goals should incorporate patient strength, endurance, flexibility, coordination, and education. This includes functional application in vocational or community settings.
2.5 POSITIVE PATIENT RESPONSE results are defined primarily as functional gains that can be objectively measured. Objective functional gains include, but are not limited to, positional tolerances, range-of-motion (ROM), strength, and endurance, activities of daily living (ADL), cognition, psychological behavior, and efficiency/velocity measures that can be quantified. Subjective reports of pain and function should be considered and given relative weight when the pain has anatomic and physiologic correlation. Anatomic correlation must be based on objective findings.
2.6 RE-EVALUATE TREATMENT EVERY 3 TO 4 WEEKS: If a given treatment or modality is not producing positive results within 3 to 4 weeks, the treatment should be either modified or discontinued. Reconsideration of diagnosis should also occur in the event of poor response to a seemingly rational intervention.
2.7 SURGICAL INTERVENTIONS: Surgery should be contemplated within the context of expected functional outcome and not purely for the purpose of pain relief. The concept of “cure” with respect to surgical treatment by itself is generally a misnomer. All operative interventions must be based upon positive correlation of clinical findings, clinical course and diagnostic tests. A comprehensive assimilation of these factors must lead to a specific diagnosis with positive identification of pathologic conditions.
2.8 SIX-MONTH TIME FRAME: The prognosis drops precipitously for returning an injured worker to work once he/she has been temporarily totally disabled for more than six months. The emphasis within these guidelines is to move patients along a continuum of care and return to work within a six-month time frame, whenever possible. It is important to note that time frames may not be pertinent to injuries that do not involve work-time loss or are not occupationally related.
2.9 RETURN-TO-WORK is therapeutic, assuming the work is not likely to aggravate the basic problem or increase long-term pain. The practitioner must provide specific physical limitations per the Physician’s Form. The following physical limitations should be considered and modified as recommended: lifting, pushing, pulling, crouching, walking, using stairs, bending at the waist, awkward and/or sustained postures, tolerance for sitting or standing, hot and cold environments, data entry and other repetitive motion tasks, sustained grip, tool usage and vibration factors. Even if there is residual chronic pain, return-to-work is not necessarily contraindicated. The practitioner should understand all of the physical demands of the patient’s job position before returning the patient to full duty and should receive clarification of the patient’s job duties.
2.10 DELAYED RECOVERY: Strongly consider a psychological evaluation, if not previously provided, as well as initiating interdisciplinary rehabilitation treatment and vocational goal setting, for those patients who are failing to make expected progress 6 to 12 weeks after an injury. A small percentage of industrially injured patients will not recover within the timelines outlined in this document despite optimal care. Such individuals may require treatments beyond the limits discussed within this document, but such treatment will require clear documentation by the authorized treating practitioner focusing on functional gains afforded by further treatment and impact upon prognosis.
2.11 GUIDELINES RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE: Guidelines are recommendations based on available evidence and/or consensus recommendations. Those procedures considered inappropriate, unreasonable, or unnecessary are designated in the guideline as being “not recommended.”
2.12 CARE BEYOND MAXIMUM MEDICAL IMPROVEMENT (MMI) should be declared when a patient’s condition reaches a plateau to the point where the authorized treating physician no longer believes further medical intervention is likely to result in improved function. However, some patients may require treatment after MMI has been declared in order to maintain their functional state. The recommendations in this guideline are for pre-MMI care and are not intended to limit post-MMI treatment.
3.1 HISTORY-TAKING AND PHYSICAL EXAMINATION (Hx & PE) are generally accepted, well-established and widely used procedures that establish the foundation/basis for and dictates subsequent stages of diagnostic and therapeutic procedures. When findings of clinical evaluations and those of other diagnostic procedures are not complementing each other, the objective clinical findings should have preference. The medical records can reasonably document the following:
3.1.1 History of Present Injury:
3.1.2 Past History:
3.1.3 Physical Examination: Examination of a joint should begin with examination of the uninjured limb and include assessment of the joint above and below the affected area of the injured limb. Physical examinations should include accepted tests as described in textbooks or other references and exam techniques applicable to the joint or region of the body being examined, including:
3.2 RADIOGRAPHIC IMAGING of the lower extremities is a generally accepted, well-established and widely used diagnostic procedure when specific indications based on history and/or physical examination are present. It should not be routinely performed. The mechanism of injury and specific indications for the radiograph should be listed on the request form to aid the radiologist and x-ray technician. For additional specific clinical indications, see Section 5.0, Specific Lower Extremity Injury Diagnosis, Testing and Treatment. Indications for initial imaging include any of the following:
3.3 LABORATORY TESTING Laboratory tests are generally accepted, well-established and widely used procedures. They are, however, rarely indicated at the time of initial evaluation, unless there is suspicion of systemic illness, infection, neoplasia, connective tissue disorder, or underlying arthritis or rheumatologic disorder based on history and/or physical examination. Laboratory tests can provide useful diagnostic information. It is recommended that lab diagnostic procedures be initially considered the responsibility of the workers' compensation carrier to ensure that an accurate diagnosis and treatment plan can be established. Tests include, but are not limited to the following:
3.4 OTHER PROCEDURES
3.4.1 Joint Aspiration is a generally accepted, well-established and widely used procedure when specifically indicated and performed by individuals properly trained in these techniques. This is true at the initial evaluation when history and/or physical examination are of concern for a septic joint or bursitis and for some acute injuries. Particularly at the knee, aspiration of a large effusion can help to decrease pain and speed functional recovery. Persistent or unexplained effusions may be examined for evidence of infection, rheumatologic, or inflammatory processes. The presence of fat globules in the effusion strongly suggests occult fracture.
3.4.2 Musculoskeletal Ultrasound. The use of diagnostic ultrasound may be beneficial for guiding injections into the pathologic areas. Ultrasound guided interventional procedure provides the ability to image soft tissues in real time and can improve safety and accuracy of needle placement. The use of ultrasound guided procedures will be at the discretion of the health care provider.
4.1 IMAGING STUDIES When indicated, the following additional imaging studies can be utilized for further evaluation of the lower extremity, based upon the mechanism of injury, symptoms, and patient history. For specific clinical indications, see Section 5.0, Specific Lower Extremity Injury Diagnosis, Testing, and Treatment. The studies below are listed in frequency of use, not importance.
4.1.1 Magnetic Resonance Imaging (MRI) are generally accepted, well-established, and widely used diagnostic procedures. It provides a more definitive visualization of soft tissue structures, including ligaments, tendons, joint capsule, menisci and joint cartilage structures, than x-ray or Computed Axial Tomography in the evaluation of traumatic or degenerative injuries. The addition of intravenous or intra-articular contrast can enhance definition of selected pathologies.
4.1.2 MR Arthrography (MRA): This accepted investigation uses the paramagnetic properties of gadolinium to shorten T1 relaxation times and provide a more intense MRI signal. It should be used to diagnose hip labral tears. Pelvic MRIs are not sufficient for this purpose. Arthrograms are also useful to evaluate mechanical pathology in knees with prior injuries and/or surgery.
4.1.3 Computed Axial Tomography (CT) is generally accepted and provides excellent visualization of bone. It is used to further evaluate bony masses and suspected fractures not clearly identified on radiographic window evaluation. Instrument scatter-reduction software provides better resolution when metallic artifact is of concern.
4.1.4 Diagnostic Sonography is an accepted diagnostic procedure. The performance of sonography is operator-dependent, and is best when done by a specialist in musculoskeletal radiology or a physician appropriately trained. e.Lineal Tomography: is infrequently used, yet may be helpful in the evaluation of joint surfaces and bone healing.
4.1.5 Bone Scan (Radioisotope Bone Scanning) is generally accepted, well-established and widely used. 99MTechnecium diphosphonate uptake reflects osteoblastic activity and may be useful in metastatic/primary bone tumors, stress fractures, osteomyelitis, and inflammatory lesions, but cannot distinguish between these entities.
4.1.6 Other Radionuclide Scanning: Indium and gallium scans are generally accepted, well-established, and widely used procedures usually to help diagnose lesions seen on other diagnostic imaging studies. 67Gallium citrate scans are used to localize tumor, infection, and abscesses. 111Indium-labeled leukocyte scanning is utilized for localization of infection or inflammation.
4.1.7 Arthrogram is an accepted diagnostic procedure. It may be useful in the evaluation of internal derangement of a joint, including when MRI or other tests are contraindicated or not available. Potential complications of this more invasive technique include pain, infection, and allergic reaction. Arthrography gains additional sensitivity when combined with CT in the evaluation of internal derangement, loose bodies, and articular cartilage surface lesions. Diagnostic arthroscopy should be considered before arthrogram when there are strong clinical indications.
4.2 OTHER DIAGNOSTIC TESTS: The following diagnostic procedures listed in this subsection are listed in alphabetical order.
4.2.1 Compartment Pressure Testing and Measurement Devices such as pressure manometer, are useful in the evaluation of patients who present symptoms consistent with a compartment syndrome.
4.2.2 Diagnostic Arthroscopy (DA) allows direct visualization of the interior of a joint, enabling the diagnosis of conditions when other diagnostic tests have failed to reveal an accurate diagnosis; however, it should generally not be employed for exploration purposes only. In order to perform a diagnostic arthroscopy, the patient must have completed at least some conservative therapy without sufficient functional recovery per Section 5.0, Specific Lower Extremity Injury Diagnosis, Testing, and Treatment, and meet criteria for arthroscopic repair.
4.2.3 Doppler Ultrasonography/Plethysmography is useful in establishing the diagnosis of arterial and venous disease in the lower extremity and should usually be considered prior to the more invasive venogram or arteriogram study. Doppler is less sensitive in detecting deep vein thrombosis in the calf muscle area. If the test is initially negative and symptoms continue, an ultrasound should usually be repeated 7 days later to rule out popliteal thrombosis. It is also useful for the diagnosis of popliteal mass when MRI is not available or contraindicated.
4.2.4 Electrodiagnostic Testing Electrodiagnostic tests include, but are not limited to Electromyography (EMG), Nerve Conduction Studies (NCS) and Somatosensory Evoked Potentials (SSEP). These are generally accepted, well-established and widely used diagnostic procedures. The SSEP study, although generally accepted, has limited use. Electrodiagnostic studies may be useful in the evaluation of patients with suspected involvement of the neuromuscular system, including disorder of the anterior horn cell, radiculopathies, peripheral nerve entrapments, peripheral neuropathies, neuromuscular junction and primary muscle disease.
4.2.5 Personality/Psychological/Psychosocial Interventions are generally accepted and well-established diagnostic procedures with selective use in the acute lower extremity population, but have more widespread use in sub-acute and chronic lower extremity populations.
4.2.6 Venogram/Arteriogram: is useful for investigation of vascular injuries or disease, including deep venous thrombosis. Potential complications may include pain, allergic reaction, and deep vein thrombosis.
4.3 SPECIAL TESTS are generally well-accepted tests and are performed as part of a skilled assessment of the patient's capacity to return-to-work, his/her strength capacities, and physical work demand classifications and tolerances. The procedures in this subsection are listed in alphabetical order.
4.3.1 Computer-Enhanced Evaluations may include isotonic, isometric, isokinetic and/or isoinertial measurement of movement, range of motion, balance, endurance or strength. Values obtained can include degrees of motion, torque forces, pressures or resistance. Indications include determining validity of effort, effectiveness of treatment and demonstrated motivation. These evaluations should not be used alone to determine return-to-work restrictions.
4.3.2 Functional Capacity Evaluation (FCE) is a comprehensive or modified evaluation of the various aspects of function as they relate to the worker's ability to return-to-work. Areas such as endurance, lifting (dynamic and static), postural tolerance, specific range of motion, coordination and strength, worker habits, employability, as well as psychosocial aspects of competitive employment may be evaluated. Components of this evaluation may include: (a) musculoskeletal screen; (b) cardiovascular profile/aerobic capacity; (c) coordination; (d) lift/carrying analysis; (e) job-specific activity tolerance; (f) maximum voluntary effort; (g) pain assessment/psychological screening; and (h) non-material and material handling activities. An FCE may be required.
4.3.3 Jobsite Analysis is a comprehensive analysis of the physical, mental and sensory components of a specific job. These components may include, but are not limited to: (a) postural tolerance (static and dynamic); (b) aerobic requirements; (c) range of motion; (d) torque/force; (e) lifting/carrying; (f) cognitive demands; (g) social interactions; (h) visual perceptual; (i) sensation; (j) coordination; (k) environmental requirements of a job; (l) repetitiveness; and (m) essential job functions including job licensing requirements. Job descriptions provided by the employer are helpful but should not be used as a substitute for direct observation. A Jobsite Analysis may be required.
4.3.4 Work Tolerance Screening (Fitness for Duty) is a determination of an individual's tolerance for performing a specific job based on a job activity or task. A Work Tolerance Screening may be required. The decision for performance of a Work Tolerance Screening should be made by the therapy provider, the treating physician, and the employer.
5.1 FOOT AND ANKLE
5.1.1 Achilles Tendonopathy or Injury and Rupture (Alternate Spelling: “Tendinopathy”):
5.1.1.1 Description/Definition: Rupture or tear of Achilles tendon or insertional or non-insertional tendonopathy.
5.1.1.2 Occupational Relationship: Usually, tears or ruptures are related to a fall, twisting, jumping, or sudden load on ankle with dorsiflexion. Tendonopathy may be exacerbated by continually walking on hard surfaces.
5.1.1.3 Specific Physical Exam Findings: Swelling and pain at tendon, sometimes accompanied by crepitus and pain with passive motion. Rupture or partial tear may present with palpable deficit in tendon. If there is a full tear, Thompson test will usually be positive. A positive Thompson's test is lack of plantar flexion with compression of the calf when the patient is prone with the knee flexed.
5.1.1.4 Diagnostic Testing Procedures: Radiography may be performed to identify Haglund’s deformity; however, many Haglund’s deformities are asymptomatic. MRI or ultrasound may be performed if surgery is being considered for tendonopathy or rupture.
5.1.1.5 Non-operative Treatment Procedures:
5.1.1.8.1 An individualized rehabilitation program based upon communication between the surgeon and the therapist using therapies as outlined in Section 6.0, Therapeutic Procedures, Non-Operative.
5.1.2 Aggravated Osteoarthritis:
5.1.2.1 Description/Definition: Internal joint pathology of ankle.
5.1.2.2 Specific Physical Exam Findings: Pain within joint, swelling. Crepitus, locking of the joint, reduced range of motion, pain with stress tests, angular deformities.
5.1.2.3 Diagnostic Testing Procedures: X-ray – mechanical axis views, CT, MRI, diagnostic injection.
5.1.2.4 Non-operative Treatment Procedures:
5.1.2.5 Surgical Indications/Considerations:
5.1.2.6 Operative Procedures: Arthroscopy, ankle arthroplasty or fusion. Supramalleolar osteotomies can be considered for patients with deformities or pre-existing hind foot varus or valgus deformities.
5.1.2.7 Post-operative Treatment:
5.1.3 Ankle or Subtalar Joint Dislocation:
5.1.3.1 Description/Definition: Dislocation of ankle or subtalar joint.
5.1.3.2 Occupational Relationship: Usually occurs with falling or twisting.
5.1.3.3 Specific Physical Exam Findings: Disruption of articular arrangements of ankle, subtalar joint may be tested using ligamentous laxity tests.
5.1.3.4 Diagnostic Testing Procedures: Radiographs, CT scans. MRI may be used to assess for avascular necrosis of the talus which may occur secondary to a dislocation.
5.1.3.5 Non-operative Treatment Procedures:
5.1.3.6 Surgical Indications/Considerations: Inability to reduce closed fracture, association with unstable fractures.
5.1.3.7 Operative Procedures: Open or closed reduction of dislocation.
5.1.3.8 Post-operative Treatment:
5.1.4 Ankle Sprain/Fracture:
5.1.4.1 Description/Definition: An injury to the ankle joint due to abnormal motion of the talus that causes a stress on the malleolus and the ligaments. Injured ligaments in order of disruption include the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), posterior talofibular ligament (PTFL), deltoid ligaments, and syndesmotic ligaments. Instability can result from a fracture of a malleolus (malleolli), rupture of ligaments, or a combination. Circumstances surrounding the injury, including consideration of location and additional injuries are of importance. Additionally, the position of the foot at the time of injury is helpful in determining the extent and type of injury. Grading of soft tissue injuries includes:
5.1.4.2 Occupational Relationship: Usually occurs from sudden twisting, direct blunt trauma and falls. Inversion of the ankle with a plantar-flexed foot is the most common mechanism of injury.
5.1.4.3 Specific Physical Exam Findings: varies with individual. With lower grade sprains the ankle may be normal appearing with minimal tenderness on examination. The ability/inability to bear weight, pain, swelling, or ecchymosis should be noted. If the patient is able to transfer weight from one foot onto the affected foot and has normal physical findings, then likelihood of fracture is reduced. Stress testing using the anterior drawer stress test, the talar tilt test and the external rotation stress test may be normal or abnormal depending on the involved ligament.
5.1.4.4 Diagnostic Testing Procedures: Radiographs. Refer to Initial Diagnostic Section which generally follows the Ottawa Ankle Rules. The Ottawa Ankle Rules are a decision aid for radiography. Commonly missed conditions include ankle syndesmosis or fractures. The instrument has a sensitivity of almost 100% and a modest specificity, and its use should reduce the number of unnecessary radiographs by 30 to 40%.
5.1.4.5 Non-operative Treatment Procedures:
5.1.4.6 Surgical Indications/Considerations:
5.1.4.7 Operative Treatment: Repair of fractures or other acute pathology as necessary. Primary ligament ankle reconstruction with possible tendon transplant.
5.1.4.8 Post-operative Treatment:
5.1.5 Calcaneal Fracture:
5.1.5.1 Description/Definition: Osseous fragmentation/separation confirmed by diagnostic studies.
5.1.5.2 Occupational Relationship: Usually occurs by fall or crush injury.
5.1.5.3 Specific Physical Exam Findings: Pain with range of motion and palpation of calcaneus. Inability to bear weight, mal-positioning of heel, possible impingement of sural nerve.
5.1.5.4 Diagnostic Testing Procedures: Radiographs and CT scan to assess for intra-articular involvement. Lumbar films and urinalysis are usually performed to rule out lumbar crush fractures when the mechanism of injury is a fall from a height.
5.1.5.5 Non-operative Treatment Procedures:
5.1.5.6 Surgical Indications/Considerations: Displacement of fragments, joint depression, intra-articular involvement, mal-position of heel. Sanders Types II and III are generally repaired surgically. However, the need for surgery will depend on the individual case. Relative contraindications: smoking, diabetes, or immunosuppressive disease.
5.1.5.7 Operative Procedures: Open reduction internal fixation. Subtalar fusion may be necessary in some cases when the calcaneus is extremely comminuted. External fixation has been used when the skin condition is poor.
5.1.5.8 Post-operative Treatment:
5.1.6 Chondral and Osteochondral Defects:
5.1.6.1 Description/Definition: Cartilage or cartilage and bone defect of the talar surface. May be associated with ankle sprain or other injuries.
5.1.6.2 Occupational Relationship: Usually caused by a traumatic ankle injury.
5.1.6.3 Specific Physical Exam Findings: Ankle effusion, pain in joint and with walking.
5.1.6.4 Diagnostic Testing Procedures: MRI may show bone bruising, osteochondral lesion, or possibly articular cartilage injury. Radiographs, contrast radiography, CT may also be used.
5.1.6.5 Non-operative Treatment Procedures:
5.1.6.6 Surgical Indications/Considerations:
5.1.6.7 Operative Procedures: Arthroscopy with debridement or shaving of cartilage, microfracture, mosiacplasty, fixation of loose osteochondral fragments.
5.1.6.8 Post-operative Treatment:
5.1.6.8.1 An individualized rehabilitation program based upon communication between the surgeon and the therapist and using therapies as outlined in Section 6.0, Therapeutic Procedures, Non-Operative. In all cases, communication between the physician and therapist is important to the timing of weight-bearing and exercise progressions.
5.1.7 Heel Spur Syndrome/Plantar Fasciitis:
5.1.7.1 Description: Pain along the inferior aspect of the heel at the calcaneal attachment of the plantar fascia and/or along the course of the plantar fascia.
5.1.7.2 Occupational Relationship: Usually, the condition may be exacerbated by prolonged standing or walking on hard surfaces. Acute injury may be caused by trauma. This may include jumping from a height or hyperextension of the forefoot upon the rear foot.
5.1.7.3 Specific Physical Exam Findings: Pain with palpation at the inferior attachment of the plantar fascia to the os calcis may be associated with calcaneal spur. Gastrocnemius tightness may be tested with the Silfverskiöld test. The foot is dorsiflexed with the knee extended and then with the knee flexed. The test for gastrocnemius tightness is considered positive if dorsiflexion is greater with the knee flexed than with the knee extended.
5.1.7.4 Diagnostic Testing Procedures: Standard radiographs to rule out fracture, identify spur after conservative therapy. Bone scans and/or MRI may be used to rule out stress fractures in chronic cases.
5.1.7.5 Non-operative Treatment Procedures:
5.1.7.6 Surgical Indications/Considerations:
5.1.7.7 Operative Treatment Procedures: Plantar fascial release with or without calcaneal spur removal, endoscopic or open gastrocnemius recession.
5.1.7.8 Post-operative Treatment:
5.1.8 Metatarsal-Phalangeal, Tarsal-Metatarsal and Interphalangeal Joint Arthropathy:
5.1.8.1 Description/Definition: Internal derangement of joint.
5.1.8.2 Occupational Relationship: Usually from jamming, contusion, crush injury, repetitive impact, or post-traumatic arthrosis.
5.1.8.3 Specific Physical Exam Findings: Pain with palpation and ROM of joint, effusion. The piano key test may be used, where the examiner stabilizes the heel with one hand and presses down on the distal head of the metatarsals, assessing for pain proximally.
5.1.8.4 Diagnostic Testing Procedures: Radiographs, diagnostic joint injection, CT, MRI.
5.1.8.5 Non-operative Treatment Procedures:
5.1.8.6 Surgical Indications/Considerations:
5.1.8.7 Operative Procedures: If debridement of the arthritic joint and other conservative treatment is unsuccessful in correcting gait and walking tolerance, other procedures may be considered. Other procedures include: fusion of first metatarsal-phalangeal joint, chilectomy, osteotomies, Keller arthroplasty and soft tissue procedures.
5.1.8.8 Post-operative Treatment:
5.1.8.8.1 An individualized rehabilitation program based upon communication between the surgeon and the therapist using therapies as outlined in Section 6.0, Therapeutic Procedures, Non-Operative. In all cases, communication between the physician and therapist is important to the timing of weight-bearing and exercise progressions.
5.1.9 Midfoot (Lisfranc) Fracture/Dislocation:
5.1.9.1 Description/Definition: Fracture/ligamentous disruption of the tarsal-metatarsal joints, i.e., metatarsal-cuneiform and metatarsal-cuboid bones.
5.1.9.2 Occupational Relationship: Usually occurs from a fall, crush, axial load with a plantar flexed foot, or abductory force on the forefoot.
5.1.9.3 Specific Physical Exam Findings: Pain and swelling at the Lisfranc joint, first and/or second metatarsal cuneiform articulation, palpable dorsal dislocation, pain on forced abduction.
5.1.9.4 Diagnostic Testing Procedures: X-rays, CT scans, MRI, mid-foot stress x-rays.
5.1.9.5 Non-operative Treatment Procedures:
5.1.9.6 Surgical Indications/Considerations: Displacement of fragments or intra-articular fracture. Most Lisfranc fracture/dislocations are treated surgically.
5.1.9.7 Operative Procedures: Open reduction internal fixation with possible removal of hardware at approximately 3 to 6 months, pending healing status. Alternatively, arthrodesis of the medial 2 or 3 metatarsals.
5.1.9.8 Post-operative Treatment:
5.1.10 Morton’s Neuroma:
5.1.10.1 Description: This condition is a perineural fibrosis of the intermetatarsal nerve creating pain and/or paresthesias in the forefoot region. Symptoms appear with weight-bearing activities. Usually occurs between the third and fourth metatarsals or between the second and third metatarsals.
5.1.10.2 Occupational Relationship: Acute injuries may include excessive loading of the forefoot region caused from jumping or pushing down on the ball of the foot. Non-traumatic occurrences are determined at physician’s discretion after review of environmental and biomechanical risk factors.
5.1.10.3 Specific Physical Exam Findings: Paresthesias and/or pain with palpation of the inter-metatarsal nerve. Mulder’s sign, a palpable click from compression of the nerve, or Tinel’s sign.
5.1.10.4 Diagnostic Testing Procedures: Radiographs to rule out osseous involvement. Diagnostic and therapeutic injections. Diagnosis is usually based on clinical judgment; however, MRI and ultrasound imaging have also been employed in difficult cases.
5.1.10.5 Non-operative Treatment Procedures:
5.1.10.6 Surgical Indications/Considerations:
5.1.10.7 Operative Procedures: Excision of the neuroma; nerve transection or transposition.
5.1.10.8 Post-operative Treatment:
5.1.11 Pilon Fracture:
5.1.11.1 Description/Definition: Crush/comminution fracture of distal metaphyseal tibia that has intra-articular extensions into the weight-bearing surface of the tibio-talar joint.
5.1.11.2 Occupational Relationship: Usually from a fall.
5.1.11.3 Specific Physical Exam Findings: Swelling, pain with weight-bearing, ecchymosis, and palpable tenderness.
5.1.11.4 Diagnostic Testing Procedures: Radiographs, CT scans.
5.1.11.5 Non-operative Treatment Procedures:
5.1.11.6 Surgical Indications/Considerations: Displacement of fracture, severe comminution necessitating primary fusion.
5.1.11.7 Operative Procedures: Open reduction internal fixation, fusion, external fixation. In some cases staged procedures may be necessary beginning with external fixation.
5.1.11.8 Post-operative Treatment:
5.1.12 Posterior Tibial Tendon Dysfunction:
5.1.12.1 Description/Definition: Pain in the posteromedial ankle with plantar flexion.
5.1.12.2 Occupational Relationship: Usually from repetitive or forced plantar flexion after an ankle sprain or athletic activity.
5.1.12.4 Diagnostic Testing Procedures: X-ray, MRI may be used to rule out other diagnoses.
5.1.12.5 Non-operative Treatment Procedures:
5.1.12.6 Surgical Indications/Considerations:
5.1.12.7 Operative Procedures: Resection of anomolous muscle segments or tenolysis. In severe cases, tendon transfer, osteotomies and/or arthrodesis may be necessary.
5.1.12.8 Post-operative Treatment:
5.1.13 Puncture Wounds of the Foot:
5.1.13.1 Description/Definition: Penetration of skin by foreign object.
5.1.13.2 Occupational Relationship: Usually by stepping on foreign object, open wound.
5.1.13.3 Specific Physical Exam Findings: Site penetration by foreign object consistent with history. In early onset, may show classic signs of infection.
5.1.13.4 Diagnostic Testing Procedures: X-ray, MRI, ultrasound.
5.1.13.5 Non-operative Treatment Procedures:
5.1.13.6 Surgical Indications/Considerations: Cellulitis, retained foreign body suspected, abscess, compartmental syndrome, and bone involvement.
5.1.13.7 Operative Procedures: Incision and drainage with cultures.
5.1.13.8 Post-operative Treatment:
5.1.14 Severe Soft Tissue Crush Injuries:
5.1.14.1 Description/Definition: Soft tissue damage to the foot.
5.1.14.2 Occupational Relationship: Usually from a crush injury or heavy impact to the foot or ankle.
5.1.14.3 Specific Physical Exam Findings: Pain and swelling over the foot.
5.1.14.4 Diagnostic Testing Procedures: X-ray and other tests as necessary to rule out other possible diagnoses such as compartment syndrome which requires emergent compartment pressure assessment.
5.1.14.5 Non-operative Treatment Procedures:
5.1.14.6 Surgical Indications/Considerations: If compartmental pressures are elevated, emergent fasciotomy is warranted.
5.1.14.7 Operative Procedures: Emergency fasciotomy. In some cases a delayed primary closure is necessary.
5.1.14.8 Post-operative Treatment:
5.1.15 Stress Fracture:
5.1.15.1 Description/Definition: Fracture without displacement usually to metatarsals, talus, navicular or calcaneus.
5.1.15.2 Occupational Relationship: May be related to repetitive, high impact walking; running; or jumping.
5.1.15.3 Specific Physical Exam Findings: Pain over the affected bone with palpation or weight-bearing.
5.1.15.4 Diagnostic Testing Procedures: X-ray, CT, MRI, bone scan
5.1.15.5 Non-operative Treatment Procedures:
5.1.15.6 Surgical Indications/Considerations: Fractures that have not responded to conservative therapy.
5.1.15.7 Operative Procedures: Most commonly percutaneous screws or plate fixation.
5.1.15.8 Post-operative Treatment:
5.1.16 Talar Fracture:
5.1.16.1 Description/Definition: Osseous fragmentation of talus confirmed by radiographic, CT or MRI evaluation.
5.1.16.2 Occupational Relationship: Usually occurs from a fall or crush injury.
5.1.16.3 Specific Physical Exam Findings: Clinical findings consistent with fracture of talus: pain with range of motion, palpation, swelling, and ecchymosis. Pain with weight-bearing attempt.
5.1.16.4 Diagnostic Testing Procedures: Radiographs, CT scans, MRI. CT scans preferred for spatial alignment.
5.1.16.5 Non-operative Treatment Procedures:
5.1.16.6 Surgical Indications/Considerations: Osseous displacement, joint involvement and instability.
5.1.16.7 Operative Procedures: Open reduction internal fixation.
5.1.16.8 Post-operative Treatment:
5.1.17 Tarsal Tunnel Syndrome:
5.1.17.1 Description: Pain and paresthesias along the medial aspect of the ankle and foot due to nerve irritation and entrapment of the tibial nerve or its branches. These symptoms can also be caused by radiculopathy.
5.1.17.2 Occupational Relationship: Acute injuries may occur after blunt trauma along the medial aspect of the foot. Non-traumatic occurrences are determined at physician’s discretion after review of environmental and biomechanical risk factors. Non work related causes include space occupying lesions.
5.1.17.3 Specific Physical Exam Findings: Positive Tinel's sign. Pain with percussion of the tibial nerve radiating distally or proximally. Pain and paresthesias with weight-bearing activities.
5.1.17.4 Diagnostic Testing Procedures: Nerve conduction velocity studies of both sides for comparison to normal side. EMGs may be needed to rule out radiculopathy. MRI to rule out space occupying lesions. Diagnostic injections to confirm the diagnosis.
5.1.17.5 Non-operative Treatment Procedures:
5.1.17.6 Surgical Indications/Considerations:
5.1.17.7 Operative Procedures: Tarsal tunnel release with or without a plantar fascial release.
5.1.17.8 Post-operative Treatment:
5.1.18 Tendonopathy:
5.2 KNEE
5.2.1 Aggravated Osteoarthritis:
5.2.1.1 Description/Definition: Swelling and/or pain in a joint due to an aggravating activity in a patient with pre-existing degenerative change in a joint. Age greater than 50 and morning stiffness lasting less than 30 minutes are frequently associated. The lifetime risk for symptomatic knee arthritis is probably around 45% and is higher among obese persons.
5.2.1.2 Other causative factors to consider - Previous meniscus or ACL damage may predispose a joint to degenerative changes. In order to entertain previous trauma as a cause, the patient should have medical documentation of the following: menisectomy; hemarthrosis at the time of the original injury; or evidence of MRI or arthroscopic meniscus or ACL damage. The prior injury should have been at least 2 years from the presentation for the new complaints and there should be a significant increase of pathology on the affected side in comparison to the original imaging or operative reports and/or the opposite un-injured side or extremity.
5.2.1.3 Specific Physical Exam Findings: Increased pain and/or swelling in a joint with joint line tenderness; joint crepitus; and/or joint deformity.
5.2.1.4 Diagnostic Testing Procedures:
5.2.1.5 Non-operative Treatment Procedures:
5.2.1.5.3 Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. They should include range-of-motion (ROM), active therapies, and a home exercise program. Active therapies include, proprioception training, restoring normal joint mechanics, and clearing dysfunctions from distal to proximal structures. Passive as well as active therapies may be used for control of pain and swelling. Therapy should progress to strengthening and an independent home exercise program targeted to further improve ROM, strength, and normal joint mechanics influenced by structures distal and proximal to the knee. Bracing may be appropriate in some instances. Refer to Section 6.0, Therapeutic Procedures, Non-operative. There is good evidence that there is a small functional advantage for patients involved in exercise with physical therapy supervision over home exercise.
5.2.1.5.4 Therapeutic Injections - Both steroids and viscosupplementation may be used.
5.2.1.6 Surgical Indications/Considerations:
5.2.1.7 Operative Procedures: Total or compartmental joint replacement, and osteotomy.
5.2.1.8 Post-operative Treatment:
5.2.2 Anterior Cruciate Ligament (ACL) Injury:
5.2.2.1 Description/Definition: Rupture or partial rupture of the anterior cruciate ligament; may be associated with other internal derangement of the knee.
5.2.2.2 Occupational Relationship: May be caused by virtually any traumatic force to the knee but most often caused by a twisting or a hyperextension force, with a valgus stress. The foot is usually planted and the patient frequently experiences a “popping” feeling.
5.2.2.3 Specific Physical Exam Findings: Findings on physical exam include effusion or hemarthrosis, instability, positive Lachman’s test, positive pivot shift test, and positive anterior drawer test.
5.2.2.4 Diagnostic Testing Procedures: MRI. Radiographs may show avulsed portion of tibial spine but this is a rare finding.
5.2.2.5 Non-operative Treatment Procedures:
5.2.2.5.4 Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. They should include range-of-motion (ROM), active therapies, and a home exercise program. Active therapies include proprioception training, restoring normal joint mechanics, and clearing dysfunctions from distal and proximal structures bracing may be beneficial. Passive as well as active therapies may be used for control of pain and swelling. Therapy should progress to strengthening and an independent home exercise program targeted to further improve ROM, strength, and normal joint mechanics influenced by structures distal and proximal to the knee (Refer to Section 6.0, Therapeutic Procedures, Non-operative). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found in Section 6.0, Therapeutic Procedures, Non-operative.
5.2.2.6 Surgical Indications/Considerations: any individual with complaints of recurrent instability interfering with function and physical findings with imaging consistent with an ACL injury.
5.2.2.7 Operative Procedures:
5.2.2.8 Post-operative Treatment:
5.2.3 Bursitis of the Lower Extremity:
5.2.3.1 Description/Definition: Inflammation of bursa tissue. Bursitis can be precipitated by tendonitis, bone spurs, foreign bodies, gout, arthritis, muscle tears, or infection.
5.2.3.2 Occupational Relationship: Usually from soft tissue trauma, contusion, or physical activities of the job such as sustained direct compression force, or other repetitive forceful activities affecting the knee.
5.2.3.3 Specific Physical Exam Findings: Palpable, tender and enlarged bursa, decreased ROM, warmth. The patient may have increased pain with ROM.
5.2.3.4 Diagnostic Testing Procedures: Lab work may be done to rule out inflammatory disease. Bursal fluid aspiration with testing for connective tissue, rheumatic disease, and infection may be necessary. Radiographs, CT, MRI are rarely indicated.
5.2.3.5 Non-operative Treatment Procedures:
5.2.3.5.4 Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. They should include range-of-motion (ROM), active therapies, including a home exercise program. Active therapies include, proprioception training, restoring normal joint mechanics, and clearing dysfunctions from distal and proximal joints. Passive as well as active therapies may be used for control of pain and swelling. Therapy should progress to strengthening and an independent home exercise program targeted to further improve ROM, strength, and normal joint mechanics influenced by structures distal and proximal to the knee. Refer to Section 6.0, Therapeutic Procedures, Non-operative.
5.2.3.6 Surgical indications/Considerations:
5.2.3.7 Operative Procedures: Surgical excision of the bursa.
5.2.3.8 Post-operative Treatment:
5.2.4 Chondral and Osteochondral Defects:
5.2.4.1 Description/Definition: Cartilage or cartilage and bone defect at the articular surface of a joint. Deficits may be identified in up to 60% of arthroscopies; however, only around 30% of these lesions are isolated deficits and even fewer are Grade III or IV deficits which might qualify for cartilage grafts.
5.2.4.2 Occupational Relationship: Typically caused by a traumatic knee injury. Chondral deficits can also be present secondary to osteoarthritis.
5.2.4.3 Specific Physical Exam Findings: Knee effusion, joint line tenderness.
5.2.4.4 Diagnostic Testing Procedures: MRI may show bone bruising, osteochondral lesion, or possibly articular cartilage injury. Radiographs, contrast radiography, CT may also be used. Diagnostic arthroscopy may be performed when surgical indications as stated in Section VI are met.
5.2.4.5 Non-operative Treatment Procedures:
5.2.4.6 Surgical Indications/Considerations: Surgery for isolated chondral defects may be indicated when functional deficits interfere with activities of daily living and/or job duties after 6 to 12 weeks of active patient participation in non-operative therapy. Identification of the lesion should have been accomplished by diagnostic testing procedures which describe the size of the lesion and stability of the joint. If a lesion is detached or has fluid underlying the bone on MRI, surgery may be necessary before a trial of conservative therapy is completed. Early surgery may consist of fixation or microfracture.
5.2.4.7 Operative Procedures: Arthroscopy with debridement or shaving of cartilage, microfracture, drilling, abrasion arthroplasty, mosiacplasty or osteochondral autograft (OATS), fixation of loose osteochondral fragments and autologous chondrocyte implantation (ACI).
5.2.4.8 Post-operative Treatment:
5.2.5 Collateral Ligament Pathology:
5.2.5.1 Description/Definition: Strain or tear of medial or lateral collateral ligaments which provide some stabilization for the knee.
5.2.5.2 Occupational Relationship: Typically a result of forced abduction and external rotation to an extended or slightly flexed knee.
5.2.5.3 Specific Physical Exam Findings: Swelling or ecchymosis over the collateral ligaments and increased laxity or pain with applied stress.
5.2.5.4 Diagnostic Testing Procedures: X-rays to rule out fracture. Imaging is more commonly ordered when internal derangement is suspected.
5.2.5.5 Non-operative Treatment Procedures:
5.2.5.5.5 Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Section 6.0, Return to Work.
5.2.5.5.6 Other therapies in Section 6.0, Therapeutic Procedures, Non-operative may be employed in individual cases.
5.2.5.6 Surgical Indications/Considerations: Surgery is rarely necessary except when functional instability persists after active participation in non-operative treatment or indications for surgery exist due to other accompanying injuries.
5.2.5.7 Operative Procedures: Surgical repair.
5.2.5.8 Post-operative Treatment:
5.2.6 Meniscus Injury:
5.2.6.1 Description/Definition: A tear, disruption, or avulsion of medial or lateral meniscus tissue. Locking of the knee or clicking is frequently reported. Patients may describe a popping, tearing, or catching sensation followed by stiffness.
5.2.6.2 Occupational Relationship: Usually, trauma to the menisci stems from rotational shearing, torsion, and/or impact injuries while in a flexed position.
5.2.6.3 Specific Physical Exam Findings: Joint line tenderness, Positive McMurray’s test locked joint, or occasionally, effusion. The presence of joint line tenderness has a sensitivity of 85% and a specificity of 31%. The Apley’s compression test is also used.
5.2.6.4 Diagnostic Testing Procedures: Radiographs including standing Posterior/Anterior (PA), lateral, tunnel, and skyline views. MRI is the definitive imaging test. MRI is sensitive and specific for meniscal tear. However, meniscal MRI is frequently abnormal in asymptomatic injuries. In one study of volunteers without a history of knee pain, swelling, locking, giving way, or any knee injury, 16% of the volunteers had MRI-evident meniscal tears; among volunteers older than 45, 36% had MRI-evident meniscal tears. Therefore, clinical correlation with history and physical exam findings specific for meniscus injury is critically important.
5.2.6.5 Non-operative Treatment:
5.2.6.6 Surgical Indications/Considerations: 1. Locked or blocked knee precluding active therapy; 2. Isolated acute meniscus tear with appropriate physical exam findings; 3. Meniscus pathology combined with osteoarthritis in a patient with functional deficits interfering with activities of daily living and/or job duties after 6 to 12 weeks of active patient participation in non-operative therapy.
5.2.6.7 Operative Treatment: Repair of meniscus, partial or complete excision of meniscus or meniscus allograft or implant. Debridement of the meniscus is not recommended in patients with severe arthritis as it is unlikely to alleviate symptoms. Complete excision of meniscus should only be performed when clearly indicated due to the long-term risk of arthritis in these patients. Partial meniscectomy or meniscus repair is preferred to total meniscectomy due to easier recovery, less instability, and short-term functional gains.
5.2.6.8 Post-operative Treatment:
5.2.7 Patellar Fracture:
5.2.7.1 Description/Definition: Fracture of the patella.
5.2.7.2 Occupational Relationship: Usually from a traumatic injury such as a fall or direct blow.
5.2.7.3 Specific Physical Exam Findings: Significant hemarthrosis/effusion usually present. Extension may be limited and may indicate disruption of the extensor mechanism. It is essential to rule out open fractures; therefore a thorough search for lacerations is important.
5.2.7.4 Diagnostic Testing Procedures: Aspiration of the joint and injection of local anesthetic may aid the diagnosis. A saline load injected in the joint can also help rule out an open joint injury. Radiographs may be performed, including tangential (sunrise) or axial views and x-ray of the opposite knee in many cases. CT or MRI is rarely needed.
5.2.7.5 Non-operative Treatment Procedures:
5.2.7.6 Surgical Indications/Considerations: Open fractures require immediate intervention and may need repeat debridement. Internal fixation is usually required for comminuted or displaced fractures. Non-union may also require surgery.
5.2.7.7 Operative Procedures: internal fixation; partial patellectomy or total patellectomy. Total patellectomy results in instability with running or stairs and significant loss of extensor strength. Therefore, this is usually a salvage procedure.
5.2.7.8 Post-operative Treatment:
5.2.8 Patellar Subluxation:
5.2.8.1 Description/Definition: Incomplete subluxation or dislocation of the patella. Recurrent episodes can lead to subluxation syndrome that can cause frank dislocation of the patella. Patient may report a buckling sensation, pain with extension, or a locking of the knee with exertion.
5.2.8.2 Occupational Relationship: Primarily associated with a direct contact lateral force. Secondary causes associated with shearing forces on the patella.
5.2.8.3 Specific Physical Exam Findings: Lateral retinacular tightness with associated medial retinacular weakness, swelling, effusion, and marked pain with patellofemoral tracking/compression and glides. In addition, other findings may include atrophy of muscles, positive patellar apprehension test, and patella alta.
5.2.8.4 Diagnostic Testing Procedures: CT or Radiographs including Merchant views, Q-angle, and MRI for loose bodies.
5.2.8.5 Non-operative Treatment Procedures:
5.2.8.6 Surgical Indications/Considerations:
5.2.8.7 Operative Procedures: arthroscopy with possible arthrotomy; debridement of soft tissue and articular cartilage disruption; open reduction internal fixation with fracture; retinacular release, quadriceps reefing, and patellar tendon or lateral release with or without medial soft-tissue realignment.
5.2.8.8 Post-operative Treatment:
5.2.9 Patellofemoral Pain Syndrome (aka Retropatellar Pain Syndrome):
5.2.9.1 Description/Definition: Patellofemoral pathologies are associated with resultant weakening, instability, and pain of the patellofemoral mechanism. Diagnoses can include patellofemoral chondromalacia, malalignment, persistent quadriceps tendonitis, distal patellar tendonitis, patellofemoral arthrosis, and symptomatic plica syndrome. Patient complains of pain, instability and tenderness that interfere with daily living and work functions such as sitting with bent knees, climbing stairs, squatting, running or cycling.
5.2.9.2 Occupational Relationship: Usually associated with contusion; repetitive patellar compressive forces; shearing articular injuries associated with subluxation or dislocation of patella, fractures, and/or infection.
5.2.9.3 Specific Physical Exam Findings: Findings on physical exam may include retinacular tenderness, pain with patellar compressive ranging, positive patellar glide test, atrophy of quadriceps muscles, positive patellar apprehensive test. Associated anatomical findings may include increased Q angle; ligament laxity, and effusion. Some studies suggest that the patellar tilt test (assessing the patella for medial tilt) and looking for active instability with the patient supine and knee flexed to 15 degrees and an isometric quad contraction, may be most useful for distinguishing normal from abnormal. Most patellar tests are more specific than sensitive.
5.2.9.4 Diagnostic Testing Procedures: Radiographs including tunnel view, axial view of patella at 30 degrees, lateral view and Merchant views. MRI rarely identifies pathology. Occasional CT or bone scans.
5.2.9.5 Non-operative Treatment Procedures:
5.2.9.5.3 Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. The program should include bracing and/or patellar taping, prone quad stretches, hip external rotation, balanced strengthening, range-of-motion (ROM), active therapies and a home exercise program. Active therapies include proprioception training, restoring normal joint mechanics, and clearing dysfunctions from distal and proximal structures. Passive as well as active therapies may be used for control of pain and swelling. Active therapeutic exercise appears to decrease pain; however, the expected functional benefits are unclear. Therapy should progress to strengthening and an independent home exercise program targeted to further improve ROM strength, and normal joint mechanics influenced by structures distal and proximal to the knee. Refer to Section 6.0, Therapeutic Procedures, Non-operative.
5.2.9.6 Surgical Indications/Considerations: patellar tendon disruption, quadriceps tendon rupture/avulsion, fracture. There is no evidence that surgery is better than eccentric training for patellar tendonopathy of the inferior pole (jumper’s knee).
5.2.9.7 Operative Procedures: Arthroscopic debridement of articular surface, plica, synovial tissue, loose bodies; arthrotomy; open reduction internal fixation with fracture; patellar prosthesis with isolated Grade III-IV OA, and possible patellectomy for young active patients with isolated arthritis.
5.2.9.8 Post-operative Treatment:
5.2.10 Posterior Cruciate Ligament (PCL) Injury:
5.2.10.1 Description/Definition: Rupture of PCL. May be associated with concurrent ACL rupture or collateral ligament injury.
5.2.10.2 Occupational Relationship: Most often caused by a posterior force directed to flexed knee.
5.2.10.3 Specific Physical Exam Findings: Findings on physical exam include acute effusion, instability, reverse Lachman’s test, reverse pivot shift, posterior drawer test.
5.2.10.4 Diagnostic Testing Procedures: MRI, radiographs including kneeling view, may reveal avulsed bone.
5.2.10.5 Non-operative Treatment Procedures:
5.2.10.6 Surgical Indications/Considerations:
5.2.10.7 Operative Procedures: Autograft or allograft reconstruction.
5.2.10.8 Post-operative Treatment:
5.2.10.8.2 Treatment may include active therapy with or without passive therapy, bracing.
5.2.11 Tendonopathy:
5.2.11.1 Description/Definition: Inflammation of the lining of the tendon sheath or of the enclosed tendon. Usually occurs at the point of insertion into bone or a point of muscular origin. Can be associated with bursitis, calcium deposits, or systemic connective diseases.
5.2.11.2 Occupational Relationship: Usually from extreme or repetitive trauma, strain, or excessive unaccustomed exercise or work.
5.2.11.3 Specific Physical Exam Findings: Involved tendons may be visibly swollen with possible fluid accumulation and inflammation; popping or crepitus; and decreased ROM.
5.2.11.4 Diagnostic Testing Procedures: Lab work may be done to rule out inflammatory disease. Other tests are rarely indicated.
5.2.11.5 Non-operative Treatment Procedures:
5.2.11.5.4 Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. They should include range-of-motion (ROM), active therapies, including a home exercise program. Active therapies include, proprioception training, restoring normal joint mechanics, and clearing dysfunctions from distal and proximal structures. Passive as well as active therapies may be used for control of pain and swelling. Therapy should progress to strengthening and an independent home exercise program targeted to further improve ROM, strength, and normal joint mechanics influenced by structures distal and proximal to the knee. Refer to Section 6.0, Therapeutic Procedures, Non-operative.
5.2.11.6 Surgical Indications/Considerations:
5.2.11.7 Operative Procedures: Tendon repair. Rarely indicated and only after extensive conservative therapy.
5.2.11.8 Post-operative Treatment:
5.3 HIP AND LEG
5.3.1 Acetabular Fracture:
5.3.1.1 Description/Definition: Subgroup of pelvic fractures with involvement of the hip articulation.
5.3.1.2 Occupational Relationship: Usually from a traumatic injury such as a fall or crush.
5.3.1.3 Specific Physical Exam Findings: Displaced fractures may have short and/or abnormally rotated lower extremity.
5.3.1.4 Diagnostic Testing Procedures: Radiographs, CT scanning.
5.3.1.5 Non-operative Treatment Procedures:
5.3.1.6 Surgical Indications/Considerations: Displaced or unstable fracture.
5.3.1.7 Operative Procedures: Usually open reduction and internal fixation or total hip replacement.
5.3.1.8 Post-operative Treatment:
5.3.2 Aggravated Osteoarthritis:
5.3.2.1 Description/Definition: hip pain with radiographic evidence of joint space narrowing or femoral acetabular osteophytes, and sedimentation rate less than 20mm/hr with symptoms. Patients usually have gradual onset of pain increasing with use and relieved with rest, progressing to morning stiffness and then to night pain.
5.3.2.2 Other causative factors to consider: Prior significant injury to the hip may predispose the joint to osteoarthritis. In order to entertain previous trauma as a cause, the patient should have a medically documented injury with radiographs or MRI showing the level of anatomic change. The prior injury should have been at least 2 years from the presentation for the new complaints and there should be a significant increase of pathology on the affected side in comparison to the original imaging or operative reports and/or the opposite un-injured side or extremity.
5.3.2.3 Specific Physical Exam Findings: Bilateral exam including knees and low back is necessary to rule out other diagnoses. Pain with the hip in external and/or internal hip rotation with the knee in extension is the strongest indicator.
5.3.2.4 Diagnostic Testing Procedures: standing pelvic radiographs demonstrating joint space narrowing to 2 mm or less, osteophytes or sclerosis at the joint. MRI may be ordered to rule out other more serious disease.
5.3.2.5 Non-operative Treatment Procedures:
5.3.2.6 Surgical Indications/Considerations:
5.3.2.6.4 Because smokers have a higher risk of non-union and post-operative costs, it is recommended that carriers cover a smoking cessation program peri-operatively. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels for long-term cessation.
5.3.2.7 Operative Procedures: Prosthetic replacement (traditional or minimally invasive), or resurfacing.
5.3.2.8 Post-operative Treatment:
5.3.3 Femoral Osteonecrosis (Avascular Necrosis (AVN) of the Femoral Head):
5.3.3.1 Description/Definition: Death of the bone tissue of the femoral head following loss of blood supply to the area. Destruction of the articular surfaces of the hip joint may lead to arthritis.
5.3.3.2 Occupational Relationship: Usually, from trauma resulting in displaced subcapital fracture of the hip or hip dislocation may cause AVN. Previous surgical procedures and systemic steroids may lead to AVN. In the general population risk factors include, but are not limited to alcohol abuse, smoking, Caisson disease (also known as the bends), sickle cell anemia, autoimmune disease, and hypercoagulable states. Often, the cause cannot be identified. Involvement of the opposite hip may occur in more than half of cases not caused by trauma.
5.3.3.3 Specific Physical Exam Findings: Hip or groin pain made worse by motion or weight-bearing and alleviated by rest is the classical presentation. Symptoms may begin gradually, often months after the vascular compromise of blood flow. A limp may result from the limited toleration of weight-bearing.
5.3.3.4 Diagnostic Testing Procedures: X-ray abnormalities include sclerotic changes, cystic lesions, joint space narrowing, and degeneration of the acetabulum. The x-ray may be normal in the first several months of the disease process. AVN should be suspected when hip pain occurs and risk factors are present. X-rays should be done first, but may be followed by an MRI. When AVN is not due to trauma, both hips should be imaged.
5.3.3.5 Non-operative Treatment Procedures:
5.3.3.6 Surgical Indications/Considerations: Core decompression may appropriate for some patients with early disease (Stages 1 and 2A) who have functionally disabling symptoms. Femoral head osteotomies or resurfacing hemiarthroplasties may also be appropriate for younger patients when disease is limited to the femoral head. Those 50 or older and patients with total joint collapse or severely limiting disease will usually require an implant arthroplasty.
5.3.3.7 Operative Procedures: Osteotomy, core decompression with or without bone graft, prosthetic replacement. Refer to Section 7.0, Therapeutic Procedures-operative for details.
5.3.3.8 Post-operative Treatment:
5.3.4 Femur Fracture:
5.3.4.1 Description/Definition: Fracture of the femur distal to the lesser trochanter.
5.3.4.2 Occupational Relationship: Usually from a traumatic injury such as a fall or crush.
5.3.4.3 Specific Physical Exam Findings: May have a short, abnormally rotated extremity. Effusion if the knee joint is involved.
5.3.4.4 Diagnostic Testing Procedures: Radiographs. Occasionally CT scan or MRI, particularly if the knee joint is involved.
5.3.4.5 Non-operative Treatment Procedures:
5.3.4.6 Surgical Indications/Considerations: Femoral neck fracture or supracondylar femur fracture with joint incongruity.
5.3.4.7 Operative Procedures: Rod placement or open internal fixation.
5.3.4.8 Post-operative Treatment:
5.3.5 Hamstring Tendon Rupture:
5.3.5.1 Description/Definition: Most commonly, a disruption of the muscular portion of the hamstring. Extent of the tear is variable. Occasionally a proximal tear or avulsion. Rarely a distal injury.
5.3.5.2 Occupational Relationship: Usually from excessive tension on the hamstring either from an injury or from a rapid, forceful contraction of the muscle.
5.3.5.3 Specific Physical Exam Findings: Local tenderness, swelling, ecchymosis.
5.3.5.4 Diagnostic Testing Procedures: Occasionally radiographs, musculoskeletal ultrasound, or MRI for proximal tears/possible avulsion.
5.3.5.5 Non-operative Treatment Procedures:
5.3.5.6 Surgical Indications/Considerations:
5.3.5.7 Operative Procedures: Re-attachment of proximal avulsions and repair of distal tendon disruption.
5.3.5.8 Post-operative Treatment:
5.3.6 Hip Dislocation:
5.3.6.1 Description/Definition: Disengagement of the femoral head from the acetabulum.
5.3.6.2 Occupational Relationship: Usually from a traumatic injury such as a fall or crush.
5.3.6.3 Specific Physical Exam Findings: Most commonly a short, internally rotated, adducted lower extremity with a posterior dislocation and a short externally rotated extremity with an anterior dislocation.
5.3.6.4 Diagnostic Testing Procedures: Radiographs, CT scanning.
5.3.6.5 Non-operative Treatment Procedures:
5.3.6.6 Surgical Indications/Considerations: Failure of closed reduction. Associated fracture of the acetabulum or femoral head, loose fragments in joint or open fracture.
5.3.6.7 Operative Procedures: Open reduction of the femoral head or acetabulum and possible internal fixation.
5.3.6.8 Post-operative Treatment Procedures:
5.3.7 Hip Fracture:
5.3.7.1 Description/Definition: Fractures of the neck and peri-trochanteric regions of the proximal femur.
5.3.7.2 Occupational Relationship: Usually from a traumatic injury such as a fall or crush. Patients with intracapsular femoral fractures have a risk of developing avascular necrosis of the femoral head requiring treatment months to years after the initial injury.
5.3.7.3 Specific Physical Exam Findings: Often a short and externally rotated lower extremity.
5.3.7.4 Diagnostic Testing Procedures: Radiographs. Occasional use of CT scan or MRI.
5.3.7.5 Non-operative Treatment Procedures:
5.3.7.6 Surgical Indications/Considerations: Surgery is indicated for unstable peritrochanteric fractures and femoral neck fractures.
5.3.7.7 Operative Procedures: Prosthetic replacement for displaced femoral neck fractures. Reduction and internal fixation for peritrochanteric fractures, and un-displaced, or minimally-displaced neck fractures.
5.3.7.8 Post-operative Treatment:
5.3.8 Impingement/Labral Tears:
5.3.8.1 Description/Definition: Two types of impingement are described pincer; resulting from over coverage of the acetabulum and/or cam; resulting from aspherical portion of the head and neck junction. Persistence of these abnormalities can cause early arthritis or labral tears. Labral tears can also be isolated; however, they are frequently accompanied by bony abnormalities. Patients usually complain of catching or painful clicking which should be distinguished from a snapping iliopsoas tibial tendon. A pinch while sitting may be reported and hip or groin pain.
5.3.8.2 Occupational Relationship: Impingement abnormalities are usually congenital; however, they may be aggravated by repetitive rotational force or trauma. Labral tears may accompany impingement or result from high energy trauma.
5.3.8.3 Specific Physical Exam Findings: Positive labral tests.
5.3.8.4 Diagnostic Testing Procedures: Cross table laterals, standing AP pelvis and frog leg lateral x-rays. MRI may reveal abnormality; however, false positives and false negatives are also possible. MRI arthrogram with gadolinium should be performed to diagnose labral tears, not a pelvic MRI. Intra-articular injection should help rule out extra-articular pain generators. To confirm the diagnosis, the patient should demonstrate changes on a pain scale accompanied by recorded functional improvement post-injection. This is important, as labral tears do not always cause pain and over-diagnosis is possible using imaging alone. Injections may be performed with or without ultrasound guidance. Ultrasound guided interventional procedure provides the ability to image soft tissues in real time and can improve safety and accuracy of needle placement. The use of ultrasound guided procedures will be at the discretion of the health care provider.
5.3.8.5 Non-operative Treatment Procedures:
5.3.8.6 Surgical Indications/Considerations:
5.3.8.7 Operative Procedures: Debridement or repair of labrum and removal of excessive bone.
5.3.8.8 Post-operative Treatment:
5.3.9 Pelvic Fracture:
5.3.9.1 Description/Definition: Fracture of one or more components of the pelvic ring (sacrum and iliac wings).
5.3.9.2 Occupational Relationship: Usually from a traumatic injury such as a fall or crush.
5.3.9.3 Specific Physical Exam Findings: Displaced fractures may cause pelvic deformity and shortening, or rotation of the lower extremities.
5.3.9.4 Diagnostic Testing Procedures: Radiographs, CT scanning. Occasionally MRI, angiogram, urethrogram, emergent sonogram.
5.3.9.5 Non-operative Treatment Procedures:
5.3.9.6 Surgical Indications/Considerations: Unstable fracture pattern, or open fracture.
5.3.9.6.1 Because smokers have a higher risk of non-union and post-operative costs, it is recommended that insurers cover a smoking cessation program peri-operatively. Physicians may monitor smoking cessation with laboratory tests such as cotinine levels for long-term cessation.
5.3.9.7 Operative Procedures: External or internal fixation dictated by fracture pattern.
5.3.9.8 Post-operative Treatment:
5.3.10 Tendonopathy: Refer to Tendonopathy in Section 5.0 for general recommendations.
5.3.11 Tibial Fracture:
5.3.11.1 Description/Definition: Fracture of the tibia proximal to the malleoli.
Open tibial fractures are graded in severity according to the Gustilo-Anderson Classification:
5.3.11.1.1 Type I: Less than 1 cm (puncture wounds).
5.3.11.1.2 Type II: 1 to 10 cm.
5.3.11.1.3 Type III-A: Greater than 10 cm, sufficient soft tissue preserved to cover the wound (includes gunshot wounds and any injury in a contaminated environment).
5.3.11.1.4 Type III-B: Greater than 10 cm, requiring a soft tissue coverage procedure.
5.3.11.1.5 Type III-C: With vascular injury requiring repair.
5.3.11.2 Occupational Relationship: Usually from a traumatic injury such as a fall or crush.
5.3.11.3 Specific Physical Exam Findings: May have a short, abnormally rotated extremity. Effusion if the knee joint involved.
5.3.11.4 Diagnostic Testing Procedures: Radiographs. CT scanning or MRI.
5.3.11.5 Non-operative Treatment Procedures:
5.3.11.6 Surgical Indications/Considerations: Unstable fracture pattern, displaced fracture (especially if the knee joint is involved), open fracture, and non-union.
5.3.11.7 Operative Procedures: Often closed rodding for shaft fractures. Open reduction and internal fixation more common for fractures involving the knee joint or pilon fractures of the distal tibia.
5.3.11.7.1 Human bone morphogenetic protein (RhBMP): this material is used for surgical repair of open tibial fractures. Refer to Section 7.0, Therapeutic Procedures, Operative for further specific information.
5.3.11.8 Post-operative Treatment:
5.3.12 Trochanteric Fracture:
5.3.12.1 Description/Definition: Fracture of the greater trochanter of the proximal femur.
5.3.12.2 Occupational Relationship: Usually from a traumatic injury such as a fall or crush.
5.3.12.3 Specific Physical Exam Findings: Local tenderness over the greater trochanter. Sometimes associated swelling, ecchymosis.
5.3.12.4 Diagnostic Testing Procedures: Radiographs, CT scans or MRI.
5.3.12.5 Non-operative Treatment Procedures:
5.3.12.6 Surgical Indications/Considerations: Large, displaced fragment, open fracture.
5.3.12.7 Operative Procedures: Open reduction, internal fixation.
5.3.12.8 Post-operative Treatment:
6.1 ACUPUNCTURE is an accepted and widely used procedure for the relief of pain and inflammation in the lower extremity. There is some scientific evidence to support its use for hip and knee osteoarthritis. The exact mode of action is only partially understood. Western medicine studies suggest that acupuncture stimulates the nervous system at the level of the brain, promotes deep relaxation, and affects the release of neurotransmitters. Acupuncture is commonly used as an alternative or in addition to traditional Western pharmaceuticals. While it is commonly used when pain medication is reduced or not tolerated, it may be used as an adjunct to physical rehabilitation and/or surgical intervention to hasten the return of functional activity. Acupuncture should be performed by MD, DC, DO with appropriate training; or a licensed acupuncturist.
6.1.1 Acupuncture: is the insertion and removal of filiform needles to stimulate acupoints (acupuncture points). Needles may be inserted, manipulated and retained for a period of time. Acupuncture can be used to reduce pain, reduce inflammation, increase blood flow, increase range-of-motion, decrease the side effect of medication-induced nausea, promote relaxation in an anxious patient, and reduce muscle spasm.
6.1.2 Acupuncture with Electrical Stimulation: is the use of electrical current (micro-amperage or milli-amperage) on the needles at the acupuncture site. It is used to increase effectiveness of the needles by continuous stimulation of the acupoint. Physiological effects (depending on location and settings) can include endorphin release for pain relief, reduction of inflammation, increased blood circulation, analgesia through interruption of pain stimulus, and muscle relaxation.
6.1.3 Total Time Frames for Acupuncture and Acupuncture with Electrical Stimulation: Time frames are not meant to be applied to each of the above sections separately. The time frames are to be applied to all acupuncture treatments regardless of the type or combination of therapies being provided.
6.1.4 Other Acupuncture Modalities: Acupuncture treatment is based on individual patient needs and therefore treatment may include a combination of procedures to enhance treatment effect. Other procedures may include the use of heat, soft tissue manipulation/massage, and exercise. Refer to Active Therapy (Therapeutic Exercise) and Passive Therapy sections (Massage and Superficial Heat and Cold Therapy) for a description of these adjunctive acupuncture modalities and time frames.
6.2 BIOFEEDBACK is a form of behavioral medicine that helps patients learn self-awareness and self-regulation skills for the purpose of gaining greater control of their physiology, such as muscle activity, brain waves, and measures of autonomic nervous system activity. Electronic instrumentation is used to monitor the targeted physiology and then displayed or fed back to the patient visually, auditorially, or tactilely, with coaching by a biofeedback specialist. Biofeedback is provided by clinicians certified in biofeedback and/or who have documented specialized education, advanced training, or direct or supervised experience qualifying them to provide the specialized treatment needed (e.g., surface EMG, EEG, or other).
6.3 BONE-GROWTH STIMULATORS
6.3.1 Electrical:  Pre-clinical and experimental literature has shown a stimulatory effect of externally applied electrical fields on the proliferation and calcification of osteoblasts and periosteal cells. All of the studies on bone growth stimulators, however, have some methodological deficiencies and high-quality literature of electrical bone growth stimulation is lacking for lower extremity injuries.
6.3.2 Low-intensity Pulsed Ultrasound: There is some evidence that low-intensity pulsed ultrasound, applied by the patient at home and administered as initial treatment of the fracture, reduces the time required for cortical bridging in tibial fractures. Non-union and delayed unions were not included in these clinical trials. Possible indications for Low-Intensity Pulsed Ultrasound are non-unions or fractures that are expected to require longer healing time.
6.4 EXTRACORPOREAL SHOCK WAVE THERAPY (ESWT)
6.5 INJECTIONS-THERAPEUTIC
6.5.1 General Description: Therapeutic injection procedures may play a significant role in the treatment of patients with lower extremity pain or pathology. Therapeutic injections involve the delivery of anesthetic and/or anti-inflammatory medications to the painful structure. Therapeutic injections have many potential benefits. Ideally, a therapeutic injection will: (a) reduce inflammation in a specific target area; (b) relieve secondary muscle spasm; (c) allow a break from pain; and (d) support therapy directed to functional recovery. Diagnostic and therapeutic injections should be used early and selectively to establish a diagnosis and support rehabilitation. If injections are overused or used outside the context of a monitored rehabilitation program, they may be of significantly less value. . All injections may be performed with or without ultrasound guidance. Ultrasound guided interventional procedures provides the ability to image soft tissues in real time and can improve safety and accuracy of needle placement. The use of ultrasound guided procedures will be at the discretion of the health care provider.
6.5.2 General Indications: Diagnostic injections are procedures which may be used to identify pain generators or pathology. For additional specific clinical indications, see Section 5.0, Specific Lower Extremity Injury Diagnosis, Testing and Treatment.
6.5.3 Special Considerations: The use of injections has become progressively sophisticated. Each procedure considered has an inherent risk, and risk versus benefit should be evaluated when considering injection therapy. In addition, all injections must include sterile technique.
6.5.4 General Contraindications: General contraindications include local or systemic infection, bleeding disorders, allergy to medications used, and patient refusal. Specific contraindications may apply to individual injections.
6.5.5 Joint Injections: are generally accepted, well-established procedures that can be performed as analgesic or anti-inflammatory procedures.
6.5.6 Soft Tissue Injections: include bursa and tendon insertions. Injections under significant pressure should be avoided as the needle may be penetrating the tendon. Injection into the tendon can cause tendon degeneration, tendon breakdown, or rupture. Injections should be minimized for patients younger than 30 years of age.
6.5.7 Trigger Point Injections: although generally accepted, have only rare indications in the treatment of lower extremity disorders. Therefore, their routine use is not recommended in the treatment of lower extremity injuries.
6.5.8 Viscosupplementation/Intracapsular Acid Salts: is an accepted form of treatment for osteoarthritis or degenerative changes in the knee joint. There is good evidence that intra-articular hyaluronic acid injections have only a small effect on knee pain and function. Therefore, the patient and treating physician should identify functional goals and the likelihood of achieving improved ability to perform activities of daily living or work activities with injections versus other treatments. The patient should agree to comply with the treatment plan including home exercise. These injections may be considered an alternative in patients who have failed non-operative treatment and surgery is not an option, particularly, if non-steroidal anti-inflammatory drug treatment is contraindicated or has been unsuccessful. Viscosupplementation is not recommended for patients with severe osteoarthritis who are surgical candidates. Its efficacy beyond 6 months is not well-established. There is no evidence that one product significantly outperforms another, prior authorization is required to approve product choice and for repeat series of injections.
6.5.9 Prototherapy: (also known as sclerotherapy) consists of peri-articular injections of hypertonic dextrose with or without phenol with the goal of inducing an inflammatory response that will recruit cytokine growth factors involved in the proliferation of connective tissue. Advocates of prolotherapy propose that these injections will alleviate complaints related to joint laxity by promoting the growth of connective tissue and stabilizing the involved joint.
6.6 JOBSITE ALTERATION
6.7 MEDICATIONS AND MEDICAL MANAGEMENT
6.7.8.1 Acetaminophen is an effective analgesic with antipyretic but not anti-inflammatory activity. Acetaminophen is generally well tolerated, causes little or no gastrointestinal irritation and is not associated with ulcer formation. Acetaminophen has been associated with liver toxicity in overdose situations or in chronic alcohol use. Patients may not realize that many over-the-counter preparations may contain acetaminophen. The total daily dose of acetaminophen is recommended not to exceed 4 grams per 24-hour period, from all sources, including narcotic-acetaminophen combination preparations.
6.7.8.2 Bisphosphonates may be used for those qualifying under osteoporosis guidelines. Long-term use for the purpose of increasing prosthetic fixation is not recommended as long-term improvement in fixation is not expected. See Section 7, h., Osteoporosis Management Section below.
6.7.8.3 Deep Venous Thrombosis Prophylaxis is a complex issue involving many variables such as individual patient characteristics, the type of surgery, anesthesia used and agent(s) used for prophylaxis. Final decisions regarding prophylaxis will depend on the surgeon’s clinical judgment. The following are provided as generally accepted concepts regarding prophylaxis at the time of writing of these guidelines.
6.7.8.4 Minor Tranquilizer/Muscle Relaxants are appropriate for muscle spasm, mild pain and sleep disorders. When prescribing these agents, physicians must seriously consider side effects of drowsiness or dizziness and the fact that benzodiazepines may be habit-forming.
6.7.8.5 Narcotics should be primarily reserved for the treatment of severe lower extremity pain. There are circumstances where prolonged use of narcotics is justified based upon specific diagnosis, and in these cases, it should be documented and justified. In mild-to-moderate cases of lower extremity pain, narcotic medication should be used cautiously on a case-by-case basis. Adverse effects include respiratory depression, the development of physical and psychological dependence, and impaired alertness.
6.7.8.6 Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are useful for pain and inflammation. In mild cases, they may be the only drugs required for analgesia. There are several classes of NSAIDs, and the response of the individual injured worker to a specific medication is unpredictable. For this reason, a range of NSAIDs may be tried in each case with the most effective preparation being continued. Patients should be closely monitored for adverse reactions. The US Food and Drug Administration advise that many NSAIDs may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal. Administration of proton pump inhibitors, histamine 2 blockers, or prostaglandin analog misoprostol along with these NSAIDs may reduce the risk of duodenal and gastric ulceration but do not impact possible cardiovascular complications. Due to the cross-reactivity between aspirin and NSAIDs, NSAIDs should not be used in aspirin-sensitive patients, and should be used with caution in all asthma patients. NSAIDs are associated with abnormal renal function, including renal failure, as well as, abnormal liver function. Certain NSAIDs may have interactions with various other medications. Individuals may have adverse events not listed above. Intervals for metabolic screening are dependent upon the patient's age, general health status and should be within parameters listed for each specific medication. Complete Blood Count (CBC) and liver and renal function should be monitored at least every six months in patients on chronic NSAIDs and initially when indicated.
6.7.8.6.1 NSAIDs may be used for pain management after joint replacement. They have also been used to reduce heterotopic ossification after arthroplasty. NSAIDs do reduce the radiographically documented heterotopic ossification in this setting, but there is some evidence that they do not improve functional outcomes and they may increase the risk of bleeding events in the post-operative period. Their routine use for prevention of heterotopic bone formation is not recommended.
6.7.8.6.2 Non-selective Nonsteroidal Anti-Inflammatory Drugs:
6.7.8.6.3.2 COX-2 inhibitors should not be first-line for low risk patients who will be using a NSAID short-term but are indicated in select patients for whom traditional NSAIDs are not tolerated. Serious upper GI adverse events can occur even in asymptomatic patients. Patients at high risk for GI bleed include those who use alcohol, smoke, are older than 65, take corticosteroids or anti-coagulants, or have a longer duration of therapy. Celecoxib is contraindicated in sulfonamide allergic patients.
6.7.8.7 Oral Steroids have limited use but are accepted in cases requiring potent anti-inflammatory drug effect in carefully selected patients. A one-week regime of steroids may be considered in the treatment of patients who have arthritic flare-ups with significant inflammation of the joint. The physician must be fully aware of potential contraindications for the use of all steroids such as hypertension, diabetes, glaucoma, peptic ulcer disease, etc., which should be discussed with the patient.
6.7.8.8 Osteoporosis Management:
6.7.8.9 Psychotropic/Anti-anxiety/Hypnotic Agents may be useful for treatment of mild and chronic pain, dysesthesias, sleep disorders, and depression. Post-operative patients may receive medication to assure normal sleep cycles. Antidepressant medications, such as tricyclics and Selective Serotonin Reuptake Inhibitors (SSRIs), are useful for affective disorder and chronic pain management. Tricyclic antidepressant agents, in low dose, are useful for chronic pain but have more frequent side effects.
6.7.8.10 Topical Drug Delivery: Creams and patches may be an alternative treatment of localized musculoskeletal disorders. It is necessary that all topical agents be used with strict instructions for application as well as the maximum number of applications per day to obtain the desired benefit and avoid potential toxicity. As with all medications, patient selection must be rigorous to select those patients with the highest probability of compliance. Refer to “Iontophoresis” in “Passive Therapy” part of this section for information regarding topical iontophoretic agents.
6.7.8.10.1 Topical Salicylates and Nonsalicylates have been shown to be effective in relieving pain in acute and chronic musculoskeletal conditions. Topical salicylate and nonsalicylates achieve tissue levels that are potentially therapeutic, at least with regard to COX inhibition. Other than local skin reactions, the side effects of therapy are minimal, although not non-existent, and the usual contraindications to use of these compounds needs to be considered. Local skin reactions are rare and systemic effects were even less common. Their use in patients receiving warfarin therapy may result in alterations in bleeding time. Overall, the low level of systemic absorption can be advantageous; allowing the topical use of these medications when systemic administration is relatively contraindicated such as is the case in patients with hypertension, cardiac failure, or renal insufficiency.
6.7.8.10.2 Capsaicin is another medication option for topical drug use in lower extremity injury. Capsaicin offers a safe and effective alternative to systemic NSAID therapy. Although it is quite safe, effective use of capsaicin is limited by the local stinging or burning sensation that typically dissipates with regular use, usually after the first 7 to 10 days of treatment. Patients should be advised to apply the cream on the affected area with a plastic glove or cotton applicator and to avoid inadvertent contact with eyes and mucous membranes.
6.7.8.10.3 Iontophoretic Agents: Refer to “Iontophoresis,” in this Section 6.0, under the subsection for Passive Therapy.
6.7.8.11 Tramadol is useful in relief of lower extremity pain and has been shown to provide pain relief equivalent to that of commonly prescribed NSAIDs. Tramadol is an atypical opioid with norepinephrine and serotonin reuptake inhibition. It is not considered a controlled substance in the U.S. Although Tramadol may cause impaired alertness, it is generally well tolerated, does not cause gastrointestinal ulceration, or exacerbate hypertension or congestive heart failure. Tramadol should be used cautiously in patients who have a history of seizures or who are taking medication that may lower the seizure threshold, such as MAO inhibitors, SSRIs, and tricyclic antidepressants. This medication has physically addictive properties and withdrawal may follow abrupt discontinuation and is not recommended for patients with prior opioid addiction.
6.8 OCCUPATIONAL REHABILITATION PROGRAMS
6.8.1 Non-Interdisciplinary: These generally accepted programs are work-related, outcome-focused, individualized treatment programs. Objectives of the program include, but are not limited to, improvement of cardiopulmonary and neuromusculoskeletal functions (strength, endurance, movement, flexibility, stability, and motor control functions), patient education, and symptom relief. The goal is for patients to gain full or optimal function and return to work. The service may include the time-limited use of passive modalities with progression to achieve treatment and/or simulated/real work.
6.8.1.1 Work Conditioning: These programs are usually initiated once reconditioning has been completed but may be offered at any time throughout the recovery phase. It should be initiated when imminent return of a patient to modified- or full-duty is not an option, but the prognosis for returning the patient to work at completion of the program is at least fair to good.
6.8.1.2 Work Simulation: is a program where an individual completes specific work-related tasks for a particular job and return-to-work. Use of this program is appropriate when modified duty can only be partially accommodated in the work place, when modified duty in the work place is unavailable, or when the patient requires more structured supervision. The need for work place simulation should be based upon the results of a Functional Capacity Evaluation and/or Jobsite Analysis.
6.9 ORTHOTICS AND PROSTHETICS
6.9.1 Fabrication/Modification of Orthotics: would be used when there is need to normalize weight-bearing, facilitate better motion response, stabilize a joint with insufficient muscle or proprioceptive/reflex competencies, to protect subacute conditions as needed during movement, and correct biomechanical problems. Footwear modifications may be necessary for work shoes and everyday shoes. Replacement is needed every six months to one year. For specific types of orthotics/prosthetics see Section 5.0, Specific Lower Extremity Injury Diagnosis, Testing and Treatment.
6.9.2 Orthotic/Prosthetic Training: is the skilled instruction (by qualified providers) in the proper use of orthotic devices and/or prosthetic limbs including stump preparation, donning and doffing limbs, instruction in wearing schedule and orthotic/prosthetic maintenance training. Training can include gait, mobility, transfer and self-care techniques.
6.9.3 Splints or Adaptive Equipment design, fabrication and/or modification indications include the need to control neurological and orthopedic injuries for reduced stress during functional activities and modify tasks through instruction in the use of a device or physical modification of a device, which reduces stress on the injury. Equipment should improve safety and reduce risk of re-injury. This includes high and low technology assistive options such as workplace modifications, crutch or walker training, and self-care aids.
6.10 PATIENT EDUCATION: No treatment plan is complete without addressing issues of individual and/or group patient education as a means of prolonging the beneficial effects of treatment, as well as facilitating self-management of symptoms and injury prevention. The patient should be encouraged to take an active role in the establishment of functional outcome goals. They should be educated on their specific injury, assessment findings, and plan of treatment. Instruction on proper body mechanics and posture, positions to avoid, self-care for exacerbation of symptoms, and home exercise should also be addressed.
6.11 PERSONALITY-PSYCHOSOCIAL-PSYCHOLOGICAL INTERVENTION: Psychosocial treatment is a generally accepted, widely used and well-established intervention. This group of therapeutic and diagnostic modalities includes, but is not limited to: individual counseling, group therapy, stress management, psychosocial crises intervention, hypnosis and meditation. Any screening or diagnostic workup should clarify and distinguish between pre-existing versus aggravated versus purely causative psychological conditions. Psychosocial intervention is recommended as an important component in the total management program that should be implemented as soon as the problem is identified. This can be used alone or in conjunction with other treatment modalities. Providers treating patients with chronic pain should refer to the Delaware Workers’ Compensation practice guidelines for Chronic Pain. Time to Produce Effect: 2 to 4 weeks.
6.12 RESTRICTION OF ACTIVITIES varies according to the specific diagnosis and the severity of the condition. Job modification/modified duty are frequently required to avoid exacerbation of the injured lower extremity. Complete work cessation should be avoided, if possible, since it often further aggravates the pain presentation. Modified return-to-work is almost always more efficacious and rarely contraindicated in the vast majority of injured workers with lower extremity injuries.
6.13 RETURN-TO-WORK: Early return-to-work should be a prime goal in treating occupational injuries given the poor return-to-work prognosis for an injured worker who has been out of work for more than six months. It is imperative that the patient be educated regarding the benefits of return-to-work, work restrictions, and follow-up if problems arise. When attempting to return a patient to work after a specific injury, clear objective restrictions of activity level should be made. An accurate job description with detailed physical duty restrictions is often necessary to assist the physician in making return-to-work recommendations. This may require a jobsite evaluation.
6.13.2 Return-to-work is defined as any work or duty that the patient is able to perform safely. It may not be the patient’s regular work. Due to the large spectrum of injuries of varying severity and varying physical demands in the work place, it is not possible to make specific return-to-work guidelines for each injury.
6.14 THERAPY – ACTIVE: The following active therapies are widely used and accepted methods of care for a variety of work-related injuries. They are based on the philosophy that therapeutic exercise and/or activity are beneficial for restoring flexibility, strength, endurance, function, range-of-motion, and can alleviate discomfort. Active therapy requires an internal effort by the individual to complete a specific exercise or task. This form of therapy requires supervision from a therapist or medical provider such as verbal, visual and/or tactile instruction(s). At times, the provider may help stabilize the patient or guide the movement pattern but the energy required to complete the task is predominately executed by the patient.
6.14.1 Activities of Daily Living (ADL) are well-established interventions which involve instruction, active-assisted training, and/or adaptation of activities or equipment to improve a person's capacity in normal daily activities such as self-care, work re-integration training, homemaking, and driving.
6.14.2 Aquatic Therapy: is a well-accepted treatment which consists of the therapeutic use of aquatic immersion for therapeutic exercise to promote ROM, flexibility, core stabilization, endurance, strengthening, body mechanics, and pain management. Aquatic therapy includes the implementation of active therapeutic procedures in a swimming or therapeutic pool. The water provides a buoyancy force that lessens the amount of force gravity applies to the body. The decreased gravity effect allows the patient to have a mechanical advantage and more likely to have a successful trial of therapeutic exercise. Studies have shown that the muscle recruitment for aquatic therapy versus similar non–aquatic motions is significantly less. Because there is always a risk of recurrent or additional damage to the muscle tendon unit after a surgical repair, aquatic therapy may be preferred by physicians to gain early return of ROM. In some cases the patient will be able to do the exercises unsupervised after the initial supervised session. Parks and recreation contacts may be used to locate less expensive facilities for patients.
6.14.3 Functional Activities are the use of therapeutic activity to enhance mobility, body mechanics, employability, coordination, balance, and sensory motor integration.
6.14.4 Functional Electrical Stimulation is the application of electrical current to elicit involuntary or assisted contractions of atrophied and/or impaired muscles. Indications include muscle atrophy, weakness, sluggish muscle contraction, neuromuscular dysfunction or peripheral nerve lesion. Indications also may include an individual who is precluded from active therapy.
6.14.5 Gait Training is specialized training that promotes normal gait for a person with a faulty gait pattern secondary to lower extremity injury or surgery. Indications include the need to promote normal gait pattern with or without assistive devices; instruct in the safety and proper use of assistive devices; instruct in progressive use of more independent devices (i.e., platform-walker, to walker, to crutches, to cane); instruct in gait on uneven surfaces and steps (with and without railings) to reduce risk of fall, or loss of balance; and/or instruct in equipment to limit weight-bearing for the protection of a healing injury or surgery.
6.14.6 Neuromuscular Re-education is the skilled application of exercise with manual, mechanical, or electrical facilitation to enhance strength; movement patterns; neuromuscular response; proprioception; kinesthetic sense; coordination; education of movement, balance and posture. Indications include the need to promote neuromuscular responses through carefully timed proprioceptive stimuli to elicit and improve motor activity in patterns similar to normal neurologically developed sequences, and improve neuromotor response with independent control.
6.14.7 Therapeutic Exercise is a generally accepted treatment with or without mechanical assistance or resistance, may include isoinertial, isotonic, isometric and isokinetic types of exercises. There is good evidence to support the functional benefits of manual therapy with exercise, walking programs, conditioning, and other combined therapy programs. Indications include the need for cardiovascular fitness, reduced edema, improved muscle strength, improved connective tissue strength and integrity, increased bone density, promotion of circulation to enhance soft tissue healing, improvement of muscle recruitment, increased range of motion and are used to promote normal movement patterns. May also include complementary/alternative exercise movement therapy.
6.14.8 Wheelchair Management and Propulsion is the instruction and training of self-propulsion and proper use of a wheelchair. This includes transferring and safety instruction. This is indicated in individuals who are not able to ambulate due to bilateral lower extremity injuries, inability to use ambulatory assistive devices, and in cases of multiple traumas.
6.15 THERAPY – PASSIVE: Most of the following passive therapies and modalities are generally well-accepted methods of care for a variety of work-related injuries. Passive therapy includes those treatment modalities that do not require energy expenditure on the part of the patient. They are principally effective during the early phases of treatment and are directed at controlling symptoms such as pain, inflammation and swelling and to improve the rate of healing soft tissue injuries. They should be use adjunctively with active therapies to help control swelling, pain, and inflammation during the rehabilitation process. They may be used intermittently as the provider deems appropriate or regularly if there are specific goals with objectively measured functional improvements during treatment.
6.15.1 Continuous Passive Motion (CPM) is a form of passive motion using specialized machinery that acts to move a joint and may also pump blood and edema fluid away from the joint and periarticular tissues. CPM is effective in preventing the development of joint stiffness if applied immediately following surgery. It should be continued until the swelling that limits motion of the joint no longer develops. ROM for the joint begins at the level of patient tolerance and is increased twice a day as tolerated. Home use of CPM is expected after chondral defect surgery. CPM may be necessary for cases with ACL repair, manipulation, joint replacement or other knee surgery if the patient has been non compliant with pre-operative ROM exercises. Use of this equipment may require home visits.
6.15.2 Contrast Baths can be used for alternating immersion of extremities in hot and cold water. Indications include edema in the sub-acute stage of healing, the need to improve peripheral circulation and decrease joint pain and stiffness.
6.15.3 Electrical Stimulation (Attended and Unattended), an accepted treatment; once applied, requires minimal on-site supervision by the physician or non-physician provider. Indications include pain, inflammation, muscle spasm, atrophy, decreased circulation, and the need for osteogenic stimulation.
6.15.4 Fluidotherapy employs a stream of dry, heated air that passes over the injured body part. The injured body part can be exercised during the application of dry heat. Indications include the need to enhance collagen extensibility before stretching, reduce muscle guarding, or reduce inflammatory response.
6.15.5 Iontophoresis is the transfer of medication, including, but not limited to, steroidal anti-inflammatory and anesthetics, through the use of electrical stimulation. Indications include pain (Lidocaine), inflammation (hydrocortisone, salicylate), edema (mecholyl, hyaluronidase, and salicylate), ischemia (magnesium, mecholyl, and iodine), muscle spasm (magnesium, calcium); calcific deposits (acetate), scars, and keloids (chlorine, iodine, acetate).
6.15.6 LASER: There is mounting evidence that low-level LASER treatment may be useful in tendonopathy, trigger points, nerve injury, and osteoarthritis of the knee. Low-level LASER treatment is therefore an accepted treatment for the above.
6.15.7 Manual Therapy Techniques are passive interventions in which the providers use his or her hands, with or without instruments, to administer skilled movements designed to modulate pain; increase joint range of motion; reduce/eliminate soft tissue swelling, inflammation, or restriction; induce relaxation; and improve contractile and non-contractile tissue extensibility. These techniques are applied only after a thorough examination is performed to identify those for whom manual therapy would be contraindicated or for whom manual therapy must be applied with caution.
6.15.7.1 Manipulation is generally accepted, well-established and widely used therapeutic intervention for lower extremity pain and dysfunction. Manipulative Treatment (not therapy) is defined as the therapeutic application of manually guided forces by an operator to improve physiologic function and/or support homeostasis that has been altered by the injury or occupational disease, and has associated clinical significance.
6.15.7.2 Mobilization (Joint) /Manipulation
6.15.7.3 Mobilization (Soft Tissue)
6.15.7.3.2 Nerve Gliding: consist of a series of flexion and extension movements of the toes, foot, knee, and hip that produce tension and longitudinal movement along the length of the sciatic, femoral, obturator, and other nerves of the lower extremity. These exercises are based on the principle that the tissues of the peripheral nervous system are designed for movement, and that tension and glide (excursion) of nerves may have an effect on neurophysiology through alterations in vascular and axoplasmic flow. Nerve gliding performed on a patient by the clinician should be reinforced by patient performance of similar techniques as part of a home exercise program at least twice per day.
6.15.8 Massage: Manual or Mechanical - Massage is manipulation of soft tissue with broad ranging relaxation and circulatory benefits. This may include stimulation of acupuncture points and acupuncture channels (acupressure), application of suction cups and techniques that include pressing, lifting, rubbing, pinching of soft tissues by or with the practitioner’s hands. Indications include edema, muscle spasm, adhesions, the need to improve peripheral circulation and range of motion, or to increase muscle relaxation and flexibility prior to exercise.
6.15.9 Paraffin Bath is a superficial heating modality that uses melted paraffin (candle wax) to treat irregular surfaces such as the foot or ankle. Indications include the need to enhance collagen extensibility before stretching, reduce muscle guarding, or reduce inflammatory response.
6.15.10 Superficial Heat and Cold Therapy: thermal agents applied in various manners that lower or raise the body tissue temperature for the reduction of pain, inflammation, and/or effusion resulting from injury or induced by exercise. Includes application of heat just above the surface of the skin at acupuncture points. Indications include acute pain, edema and hemorrhage, need to increase pain threshold, reduce muscle spasm and promote stretching/flexibility. Cold and heat packs can be used at home as an extension of therapy in the clinic setting.
6.15.10.3 Maximum duration: 18 12 visits, with maximum visits of 1 per day. If symptoms persist, consideration should be given to further diagnostic studies or other treatment options.
6.15.11 Short-wave Diathermy is an accepted treatment which involves the use of equipment that exposes soft tissue to a magnetic or electrical field. Indications include enhanced collagen extensibility before stretching, reduced muscle guarding, reduced inflammatory response, and enhanced re-absorption of hemorrhage/hematoma or edema. It is an accepted modality as an adjunct to acupuncture or situation where other forms of contact superficial heat are contraindicated.
6.15.12 Therapeutic Taping/Strapping: Fabrication and application of strapping or taping (e.g. use of elastic wraps, heavy cloths, or adhesive tape) are used to enhance performance of tasks for movements, support weak or ineffective joints or muscles, reduce or correct joint limitations or deformities, and/or protect body parts from injury. Splints and strapping are also used in conjunction with therapeutic exercise, functional training and other interventions, and should be selected in the context of the patient’s need. Examples include, but are not limited to, strains and sprains of joints, patello femoral syndrome, and post surgical rehabilitation.
6.15.13 Transcutaneous Electrical Nerve Stimulation (TENS) is a generally accepted treatment. TENS should include at least one instructional session for proper application and use. Indications include muscle spasm, atrophy, and decreased circulation and pain control. Minimal TENS unit parameters should include pulse rate, pulse width and amplitude modulation. Consistent, measurable functional improvement must be documented prior to the purchase of a home unit.
6.15.14 Ultrasound is an accepted treatment which includes ultrasound with electrical stimulation and Phonophoresis. Ultrasound uses sonic generators to deliver acoustic energy for therapeutic thermal and/or non-thermal soft tissue effects. Indications include scar tissue, adhesions, collagen fiber and muscle spasm, and the need to extend muscle tissue or accelerate the soft tissue healing.
6.15.15 Vasopneumatic Devices are mechanical compressive devices used in both inpatient and outpatient settings to reduce various types of edema. Indications include pitting edema, lymphedema and venostasis. Maximum compression should not exceed minimal diastolic blood pressure. Use of a unit at home should be considered if expected treatment is greater than two weeks.
6.15.16 Whirlpool is conductive exposure to water at temperatures that best elicits the desired effect (cold vs. heat). It generally includes massage by water propelled by a turbine or Jacuzzi jet system and has the same thermal effects as hot packs if higher than tissue temperature. It has the same thermal effects as cold application if comparable temperature water used. Indications include the need for analgesia, relaxing muscle spasm, reducing joint stiffness, enhancing mechanical debridement and facilitating and preparing for exercise.
6.16 VOCATIONAL REHABILITATION is a generally accepted intervention. Initiation of vocational rehabilitation requires adequate evaluation of patients for quantification of highest functional level and motivation. Vocational rehabilitation may be as simple as returning to the original job or as complicated as being retrained for a new occupation. The effectiveness of vocational rehabilitation may be enhanced when performed in combination with work hardening or work conditioning.
7.1 ANKLE AND SUBTALAR FUSION
7.1.1 Description/Definition: Surgical fusion of the ankle or subtalar joint.
7.1.2 Occupational Relationship: Usually post-traumatic arthritis or residual deformity.
7.1.3 Specific Physical Exam Findings: Painful, limited range of motion of the joint(s). Possible fixed deformity.
7.1.4 Diagnostic Testing Procedures: Radiographs. Diagnostic injections, MRI, CT scan, and/or bone scan.
7.1.5 Surgical Indications/Considerations: All reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented. Patient has disabling pain or deformity. Fusion is the procedure of choice for individuals with osteoarthritis who plan to return to physically demanding activities.
7.1.6 Operative Procedures: Open reduction internal fixation (ORIF) with possible bone grafting. External fixation may be used in some cases.
7.1.7 Post-operative Treatment:
7.2 KNEE FUSION
7.2.1 Description/Definition: Surgical fusion of femur to the tibia at the knee joint.
7.2.2 Occupational Relationship: Usually from post-traumatic arthritis or deformity.
7.2.3 Specific Physical Exam Findings: Stiff, painful, sometime deformed limb at the knee joint.
7.2.4 Diagnostic Testing Procedures: Radiographs. MRI, CT, diagnostic injections or bone scan.
7.2.5 Surgical Indications/Considerations: All reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented, e.g. failure of arthroplasty. Fusion is a consideration particularly in the young patient who desires a lifestyle that would subject the knee to high mechanical stresses. The patient should understand that the leg will be shortened and there may be difficulty with sitting in confined spaces, and climbing stairs. Although there is generally a painless knee, up to 50% of cases may have complications.
7.2.6 Operative Procedures: Open reduction internal fixation (ORIF) with possible bone grafting. External fixation or intramedullary rodding may also be used.
7.2.7 Post-operative Treatment:
7.3 ANKLE ARTHROPLASTY
7.3.1 Description/Definition: Prosthetic replacement of the articulating surfaces of the ankle joint.
7.3.2 Occupational Relationship: Usually from post-traumatic arthritis.
7.3.3 Specific Physical Exam Findings: Stiff, painful ankle. Limited range-of-motion of the ankle joint.
7.3.4 Diagnostic Testing Procedures: Radiographs, MRI, diagnostic injections, CT scan, bone scan.
7.3.5 Surgical Indications/Considerations: When pain interferes with ADLs, and all reasonable conservative measures have been exhausted and other reasonable surgical options have been considered or implemented. A very limited population of patients is appropriate for ankle arthroplasty.
7.3.5.4 Contraindications include severe osteoporosis, significant general disability due to other medical conditions, psychiatric issues.
7.3.6 Operative Procedures: Prosthetic replacement of the articular surfaces of the ankle; DVT prophylaxis is not always required but should be considered for patients who have any risk factors for thrombosis.
7.3.6.1 Complications – include pulmonary embolism, infection, bony lysis, polyethylene wear, tibial loosening, instability, malalignment, stiffness, nerve-vessel injury, and peri-prosthetic fracture.
7.3.7 Post-operative Treatment:
7.3.7.2 NSAIDs may be used for pain management after joint replacement. They have also been used to reduce heterotopic ossification after ankle arthroplasty. NSAIDs do reduce the radiographically documented heterotopic ossification in this setting, but there is some evidence (in literature on hip arthroplasty) that they do not improve functional outcomes and they may increase the risk of bleeding events in the post-operative period. Their routine use for prevention of heterotopic bone formation is not recommended.
7.4 KNEE ARTHROPLASTY
7.4.1 Description/Definition: Prosthetic replacement of the articulating surfaces of the knee joint.
7.4.2 Occupational Relationship: Usually from post-traumatic osteoarthritis.
7.4.3 Specific Physical Exam Findings: Stiff, painful knee, and possible effusion.
7.4.4 Diagnostic Testing Procedures: Radiographs.
7.4.5 Surgical Indications/Considerations: Severe osteoarthritis and all reasonable conservative measures have been exhausted and other reasonable surgical options have been considered or implemented. Significant changes such as advanced joint line narrowing are expected. Refer to Aggravated Osteoarthritis in Section 5.0
7.4.5.2 Contraindications - severe osteoporosis, significant general disability due to other medical conditions, psychiatric issues.
7.4.5.4 Prior to surgical intervention, the patient and treating physician should identify functional activities and the patient should agree to comply with the pre- and post-operative treatment plan including home exercise. The provider should be especially careful to make sure the patient understands the amount of post-operative therapy required and the length of partial- and full-disability expected post-operatively.
7.4.6 Operative Procedures: Prosthetic replacement of the articular surfaces of the knee; total or uni-compartmental with DVT prophylaxis. May include patellar resurfacing and computer assistance.
7.4.6.3 Complications occur in around 3% and include pulmonary embolism; infection, bony lysis, polyethylene wear, tibial loosening, instability, malalignment, stiffness, patellar tracking abnormality, nerve-vessel injury, and peri-prosthetic fracture.
7.4.7 Post-operative Treatment:
7.4.7.2 NSAIDs may be used for pain management after joint replacement. They have also been used to reduce heterotopic ossification after knee arthroplasty. NSAIDs do reduce the radiographically documented heterotopic ossification in this setting, but there is some evidence (in literature on total hip arthroplasty) that they do not improve functional outcomes and they may increase the risk of bleeding events in the post-operative period. Their routine use for prevention of heterotopic bone formation is not recommended.
7.5 HIP ARTHROPLASTY
7.5.1 Description/Definition: Prosthetic replacement of the articulating surfaces of the hip joint. In some cases, hip resurfacing may be performed.
7.5.2 Occupational Relationship: Usually from post-traumatic arthritis, hip dislocations and femur or acetabular fractures. Patients with intracapsular femoral fractures have a risk of developing avascular necrosis of the femoral head requiring treatment months to years after the initial injury.
7.5.3 Specific Physical Exam Findings: Stiff, painful hip.
7.5.4 Diagnostic Testing Procedures: Standing pelvic radiographs demonstrating joint space narrowing to 2 mm or less, osteophytes or sclerosis at the joint. MRI may be ordered to rule out other more serious disease.
7.5.5 Surgical Indications/Considerations: Severe osteoarthritis and all reasonable conservative measures have been exhausted and other reasonable surgical options have been considered or implemented. Refer to Aggravated Osteoarthritis in Section 5.0
7.5.5.1 Possible contraindications - inadequate bone density, prior hip surgery, and obesity.
7.5.6 Operative Procedures: Prosthetic replacement of the articular surfaces of the hip, ceramic or metal prosthesis, with DVT prophylaxis. Ceramic prosthesis is more expensive; however, it is expected to have greater longevity and may be appropriate in some younger patients. Hip resurfacing, metal on metal, is an option for younger or active patients likely to out-live traditional total hip replacements.
7.5.6.1 Complications include leg length inequality, deep venous thrombosis with possible pulmonary embolus, hip dislocation, possible renal effects, need for transfusions, future infection, need for revisions, fracture at implant site.
7.5.7 Post-operative Treatment:
7.5.7.2 NSAIDs may be used for pain management after joint replacement. They have also been used to reduce heterotopic ossification after hip arthroplasty. NSAIDs do reduce the radiographically documented heterotopic ossification in this setting, but there is some evidence that they do not improve functional outcomes and they may increase the risk of bleeding events in the post-operative period. Their routine use for prevention of heterotopic bone formation is not recommended.
7.6 AMPUTATION
7.6.1 Description/Definition: Surgical removal of a portion of the lower extremity.
7.6.2 Occupational Relationship: Usually secondary to post-traumatic bone, soft tissue, vascular or neurologic compromise of part of the extremity.
7.6.3 Specific Physical Exam Findings: Non-useful or non-viable portion of the lower extremity.
7.6.4 Diagnostic Testing Procedures: Radiographs, vascular studies, MRI, bone scan.
7.6.5 Surgical Indications/Considerations: Non-useful or non-viable portion of the extremity.
7.6.6 Operative Procedures: Amputation.
7.6.7 Post-operative Treatment:
7.7 MANIPULATION UNDER ANESTHESIA
7.7.1 Description/Definition: Passive range of motion of a joint under anesthesia.
7.7.2 Occupational Relationship: Typically from joint stiffness that usually results from a traumatic injury, compensation related surgery, or other treatment.
7.7.3 Specific Physical Exam Findings: Joint stiffness in both active and passive modes.
7.7.4 Diagnostic Testing Procedures: Radiographs. CT, MRI, diagnostic injections.
7.7.5 Surgical Indications/Considerations: Consider if routine therapeutic modalities, including therapy and/or dynamic bracing, do not restore the degree of motion that should be expected after a reasonable period of time, usually at least 12 weeks.
7.7.6 Operative Treatment: Not applicable.
7.7.7 Post-operative Treatment:
7.8 OSTEOTOMY
7.8.1 Description/Definition: A reconstructive procedure involving the surgical cutting of bone for realignment. It is useful for patients that would benefit from realignment in lieu of total joint replacement.
7.8.2 Occupational Relationship: Usually, post-traumatic arthritis or deformity.
7.8.3 Specific Physical Exam Findings: Painful decreased range of motion and/or deformity.
7.8.4 Diagnostic Testing Procedures: Radiographs, MRI scan, CT scan.
7.8.5 Surgical Indications/Considerations: Failure of non-surgical treatment when avoidance of total joint arthroplasty is desirable. For the knee, joint femoral osteotomy may be desirable for young or middle age patients with varus alignment and medial arthritis or valgus alignment and lateral compartment arthritis. High tibial osteotomy is also used for medial compartment arthritis. Multi-compartmental degeneration is a contraindication. Patients should have a range of motion of at least 90 degrees of knee flexion. For the ankle supra malleolar osteotomy may be appropriate. High body mass is a relative contraindication.
7.8.6 Operative Procedures: Peri-articular opening or closing wedge of bone, usually with grafting and internal or external fixation.
7.8.6.1 Complications - new fractures, lateral peroneal nerve palsy, infection, delayed unions, compartment syndrome, or pulmonary embolism.
7.8.7 Post-operative Treatment:
7.9 HARDWARE REMOVAL Hardware removal frequently occurs after initial MMI. Physicians should document the possible need for hardware removal and include this as treatment in their final report on the WC 164 form.
7.9.1 Description/Definition: Surgical removal of internal or external fixation device, commonly related to fracture repairs.
7.9.2 Occupational Relationship: Usually following healing of a post-traumatic injury that required fixation or reconstruction using instrumentation.
7.9.3 Specific Physical Exam Findings: Local pain to palpation, swelling, erythema.
7.9.4 Diagnostic Testing Procedures: Radiographs, tomography, CT scan, MRI.
7.9.5 Surgical Indications/Considerations: Persistent local pain, irritation around hardware.
7.9.6 Operative Procedures: Removal of hardware may be accompanied by scar release/resection, and/or manipulation. Some instrumentation may be removed in the course of standard treatment without symptoms of local irritation.
7.9.7 Post-operative Treatment:
7.10 RELEASE OF CONTRACTURE
7.10.1 Description/Definition: Surgical incision or lengthening of contracted tendon or peri-articular soft tissue.
7.10.2 Occupational Relationship: Usually following a post-traumatic complication.
7.10.3 Specific Physical Exam Findings: Shortened tendon or stiff joint.
7.10.4 Diagnostic Testing Procedures: Radiographs, CT scan, MRI scan.
7.10.5 Surgical Indications/Considerations: Persistent shortening or stiffness associated with pain and/or altered function.
7.10.6 Operative Procedures: Surgical incision or lengthening of involved soft tissue.
7.10.7 Post-operative Treatment:
7.11 Human Bone Morphogenetic Protein (RhBMP): (RhBMP) is a member of a family of proteins which are involved in the growth, remodeling, and regeneration of bone tissue. It has become available as a recombinant biomaterial with osteo-inductive potential for application in long bone fracture non-union and other situations in which the promotion of bone formation is desired. RhBMP may be used with intramedullary rod treatment for open tibial fractures an open tibial Type III A and B fracture treated with an intramedullary rod. There is some evidence that it decreases the need for further procedures when used within 14 days of the injury.  It should not be used in those with allergies to the preparation, or in females with the possibility of child bearing, or those without adequate neurovascular status or those less than 18 years old. Ectopic ossification into adjacent muscle has been reported to restrict motion in periarticular fractures. Other than for tibial open fractures as described above, it should be used principally for non-union of fractures that have not healed with conventional surgical management or peri-prosthetic fractures.
Last Updated: December 31 1969 19:00:00.
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