DEPARTMENT OF LABOR
Division of Industrial Affairs
Office of Workers’ Compensation
Statutory Authority: 19 Delaware Code, Sections 2322B, C, E, and F (19 Del.C. §§2322B, C, E, and F)
19 DE Admin Code 1342
 
final
 
ORDER
 
1342 Health Care Practice Guidelines; PART G Lower Extremity Treatment Guidelines
 
A public meeting was held on May 2, 2011, by the Department of Labor to receive public comments relating to a 7th health care practice guideline – Lower Extremities. The members of the Health Care Advisory Panel (“HCAP”), signed below, recommend that the Secretary of Labor adopt this proposal as it was published in the Register of Regulations, Volume 14, Issue 10 (April 2011).
 
SUMMARY OF THE EVIDENCE AND INFORMATION SUBMITTED
 
Exhibits Admitted:
Exhibit 1 – News Journal, Affidavit of publication of notice of public meeting.
Exhibit 2 – Delaware State News, Affidavit of publication of notice of public meeting.
 
No written comments were received by the Delaware Department of Labor. After the Panel concluded with their introductions, the public was invited to share their comments. No members of the public were in attendance at the public meeting.
 
The following comments were made during the public meeting.
 
Lower Extremities Health Care Practice Guidelines:
No Public Comment
 
The Panel voted unanimously to recommend approval of the Lower Extremities Health Care Practice Guidelines.
 
Therefore, the HCAP agreed to submit and recommend for adoption by the Delaware Department of Labor the revisions to the 7th health care practice guideline – Lower Extremities.
 
RECOMMENDED FINDINGS OF FACT WITH RESPECT TO THE EVIDENCE AND INFORMATION
 
The HCAP is persuaded that the proposals are consistent with administrating the statutory directives in the workers’ compensation law.
 
RECOMMENDATION
 
The proposals are respectfully submitted to the Secretary of Labor for consideration with a recommendation for adoption this 2nd day of May, 2011.
 
HEALTH CARE ADVISORY PANEL
 
DECISION AND EFFECTIVE DATE
 
Having reviewed and considered the record and recommendations of members of the Health Care Advisory Panel to adopt revisions adding a 7th health care practice guideline – Lower Extremities. The Guidelines are hereby adopted by the Delaware Department of Labor and made effective June 13, 2011.
 
TEXT AND CITATION
 
The proposed Lower Extremities health care practice guideline notice appeared in the Register of Regulations, Volume 14, Issue 10 (April 1, 2011). The Lower Extremities Practice Guideline are available from the Department of Labor, Division of Industrial Affairs, Office of Workers’ Compensation or on the department’s website: www.delawareworks.com.
 
DEPARTMENT OF LABOR
John McMahon, Secretary of Labor
 
1342 Health Care Practice Guidelines
PART G Lower Extremity Treatment Guidelines
 
1.0 Introduction
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. 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 rendered outside the Guidelines or variation in treatment recommendations from the Guidelines may represent acceptable medical care, be considered reasonable and necessary treatment and, therefore, determined to be compensable, absent evidence to the contrary, and may be payable in accordance with the Fee Schedule and Statute, accordingly.
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).
Treatment of conditions unrelated to the injuries sustained in an industrial accident may be denied as unauthorized if the treatment is directed toward the non-industrial condition, unless the treatment of the unrelated injury is rendered necessary as a result of the industrial accident.
The Health Care Advisory Panel and Department of Labor recognizes that acceptable medical practice may include deviations from these Guidelines, as individual cases dictate. Therefore, these Guidelines are not relevant as evidence of a provider's legal standard of professional care.
In accordance with the requirements of the Act, the development of the health care guidelines has been directed by a predominantly medical or other health professional panel, with recommendations then made to the Health Care Advisory Panel.
 
2.0 General Guideline Principles
The principles summarized in this section are key to the intended implementation of all Delaware Workers’ Compensation practice guidelines and critical to the reader’s application of the guidelines in this document.
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.
2.2.1 Lower extremity injuries are often not isolated and frequently compensation for injury in one area may result in symptoms or dysfunction in another area. Additionally, weakness or dysfunction in an adjacent or otherwise remote body region may be a predisposing or perpetuating factor for the injured area. Therefore, treatment applied to adjacent body regions is often required for the recovery of lower extremity injuries. The provider’s documentation should clearly include the rationale for treating adjacent or remote body regions, as well as include the specific interventions provided.
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.
 
3.0 Initial Diagnostic Procedures
The guidelines recommend the following diagnostic procedures be considered, at least initially. It is the responsibility of the workers’ compensation carrier to ensure that an accurate diagnosis and treatment plan can be established. Standard procedures that should be utilized when initially diagnosing a work-related lower extremity complaint are listed below.
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:
3.1.1.1 Mechanism of injury. This includes details of symptom onset and progression. It should include such details as: the activity at the time of the injury, patient description of the incident, and immediate and delayed symptoms. The history should elicit as much detail about these mechanisms as possible.
3.1.1.2 History of locking, clicking, popping, giving way, acute or chronic swelling, crepitation, pain while ascending or descending stairs (e.g. handrail used, ‘foot by foot’ instead of ‘foot over foot’) inability to weight bear due to pain, intolerance for standing or difficulty walking distances on varied surfaces, difficulty crouching or stooping, and wear patterns on footwear. Patients may also report instability or mechanical symptoms.
3.1.1.3 Any history of pain in back as well as joints distal and proximal to the site of injury. The use of a patient completed pain drawing, Visual Analog Scale (VAS), is highly recommended, especially during the first two weeks following injury to assure that all work related symptoms are addressed.
3.1.1.4 Ability to perform job duties and activities of daily living.
3.1.1.5 Exacerbating and alleviating factors of the reported symptoms. The physician should explore and report on non-work related as well as, work related activities.
3.1.1.6 Prior occupational and non-occupational injuries to the same area including specific prior treatment and any prior bracing devices.
3.1.1.7 Discussion of any symptoms present in the uninjured extremity.
3.1.2 Past History:
3.1.2.1 Past medical history includes neoplasm, gout, arthritis, previous musculoskeletal injuries, and diabetes;
3.1.2.2 Review of systems includes symptoms of rheumatologic, neurological, endocrine, neoplastic, and other systemic diseases;
3.1.2.3 History of smoking, alcohol use, and substance abuse;
3.1.2.4 History of corticosteroid use; and
3.1.2.5 Vocational and recreational pursuits.
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:
3.1.3.1 Visual inspection;
3.1.3.1.1 Swelling may indicate joint effusion from trauma, infection or arthritis. Swelling or bruising over ligaments or bones can indicate possible fractures or ligament damage;
3.1.3.2 Palpation for joint line tenderness, effusion, and bone or ligament pain;
3.1.3.2.1 Palpation may be used to assess tissue tone and contour; myofascial trigger points; and may be graded for intensity of pain. Palpation may be further divided into static and motion palpation. Static palpation consists of feeling bony landmarks and soft tissue structures and consistency. Motion palpation is commonly used to assess joint movement patterns and identify joint dysfunction;
3.1.3.3 Assessment of activities of daily living including gait abnormalities, especially after ambulating a distance and difficulties ascending/descending stairs;
3.1.3.3.4 Assessment of activities such as the inability to crouch or stoop, may give important indications of the patient’s pathology and restrictions.
3.1.3.4 Range-of-motion and quality-of-motion should be assessed actively and passively;
3.1.3.5 Strength;
3.1.3.6 Joint stability;
3.1.3.7 Hip exam;
3.1.3.7.1 In general, multiple tests are needed to reliably establish a clinical diagnosis. Spinal pathology and groin problems should always be considered and ruled out as a cause of pain for patients with hip symptomatology. The following lists commonly performed tests:
3.1.3.7.1.1 Flexion-Abduction-External Rotation (FABER-aka Patrick’s) test is frequently used as a test for sacral pathology;
3.1.3.7.1.2 Log roll test may be used to assess iliofemoral joint laxity;
3.1.3.7.1.3 Ober’s is used to test the iliotibial band;
3.1.3.7.1.4 Greater trochanter bursitis is aggravated by external rotation and adduction and resisted hip abduction or external rotation;
3.1.3.7.1.5 Iliopectineal bursitis may be aggravated by stretching the tendon in hip extension;
3.1.3.7.1.6 Internal and external rotation is usually painful in osteoarthritis; and
3.1.3.7.1.7 The maneuvers of flexion, adduction and internal rotation (FADIR) will generally reproduce pain in cases of labral tears and with piriformis strain/irritation.
3.1.3.8 Knee exam;
3.1.3.8.1 In general, multiple tests are needed to reliably establish a clinical diagnosis. The expertise of the physician performing the exam influences the predictability of the exam findings. Providers should be aware that patients with osteoarthritis may have positive pain complaints with various maneuvers based on their osteoarthritis rather than ligamentous or meniscal damage. The following partial list contains commonly performed tests:
3.1.3.8.1.1 Bilateral thigh circumference measurement assesses for quadriceps wasting which may occur soon after a knee injury. The circumferences of both thighs should be documented approximately 15 cm above a reference point, either the joint line or patella.
3.1.3.8.1.2 Anterior Cruciate Ligament tests:
3.1.3.8.1.2.1 Lachman’s test;
3.1.3.8.1.2.2 Anterior drawer test;
3.1.3.8.1.2.3 Lateral pivot shift test.
3.1.3.8.1.3 Meniscus tests. Joint line tenderness and effusions are common with acute meniscal tears. Degenerative meniscal tears are fairly common in older patients with degenerative changes and may be asymptomatic.
3.1.3.8.1.3.1 McMurray test;
3.1.3.8.1.3.2 Apley compression test;
3.1.3.8.1.3.3 Medial lateral grind test;
3.1.3.8.1.3.4 Weight-bearing tests - include Thessaly and Ege’s test.
3.1.3.8.1.4 Posterior Cruciate Ligament tests:
3.1.3.8.1.4.1 Posterior drawer test;
3.1.3.8.1.4.2 Extension lag may also be measured passively by documenting the heel height difference with the patient prone.
3.1.3.8.1.5 Collateral Ligaments tests:
3.1.3.8.1.5.1 Medial stress test – A positive test in full extension may include both medial collateral ligament and cruciate ligament pathology;
3.1.3.8.1.5.2 Lateral stress test.
3.1.3.8.1.6 Patellar Instability tests:
3.1.3.8.1.6.1 Apprehension test;
3.1.3.8.1.6.2 J sign;
3.1.3.8.1.6.3 Q angle.
3.1.3.9 Foot and ankle exam:
3.1.3.9.1 In general, multiple tests are needed to reliably establish a clinical diagnosis. The expertise of the physician performing the exam influences the predictability of the exam findings. Ankle assessments may include anterior drawer exam, talar tilt test, external rotation stress test, ankle ligament stress test and the tibia-fibula squeeze test. Achilles tendon may be assessed with the Thompson's test. Foot examinations may include, assessment of or for: subtalar, midtarsal, and metatarsal-phalangeal joints; tarsal tunnel; and posterior tibial tendon; Morton's neuroma; the piano key test and Lisfranc injury.
3.1.3.10 If applicable, full neurological exam including muscle atrophy and gait abnormality.
3.1.3.11 If applicable to injury, integrity of distal circulation, sensory, and motor function.
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:
3.2.1 The inability to flex knee to 90 degrees or to transfer weight for four steps at the time of the immediate injury and at the initial visit, regardless of limping;
3.2.2 Bony tenderness on any of the following areas: over the head of the fibula; isolated to the patella; of the lateral or medial malleolus from the tip to the distal 6 cm; at the base of the 5th metatarsal; or at the navicular;
3.2.3 History of significant trauma, especially blunt trauma or fall from a height;
3.2.4 Age over 55 years;
3.2.5 History or exam suggestive of intravenous drug abuse or osteomyelitis;
3.2.6 Pain with swelling and/or range of motion (ROM) limitation localizing to an area of prior fracture, internal fixation, or joint prosthesis; or
3.2.7 Unexplained or persistent lower extremity pain over two weeks.
3.2.7.1 Occult fractures, especially stress fractures, may not be visible on initial x-ray. A follow-up radiograph, MRI and/or bone scan may be required to make the diagnosis.
3.2.7.2 Weight-bearing radiographs are used to assess osteoarthritis and alignment prior to some surgical procedures.
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:
3.3.1 Complete blood count (CBC) with differential can detect infection, blood dyscrasias, and medication side effects;
3.3.2 Erythrocyte sedimentation rate, rheumatoid factor, antinuclear antigen (ANA), human leukocyte antigen (HLA), and C-reactive protein (CRP) can be used to detect evidence of a rheumatologic, infection, or connective tissue disorder;
3.3.3 Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect metabolic bone disease;
3.3.4 Liver and kidney function may be performed for prolonged anti-inflammatory use or other medications requiring monitoring; and
3.3.5 Analysis of joint aspiration for bacteria, white cell count, red cell count, fat globules, crystalline birefringence and chemistry to evaluate joint effusion.
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.
3.4.1.1 Risk factors for septic arthritis include joint surgery, knee arthritis, joint replacement, skin infection, diabetes, age greater than 80, immunocompromised states, and rheumatoid arthritis. More than 50% of patients with septic joints have a fever greater than 37.5 degrees centigrade and joint swelling. Synovial white counts of greater than 25,000 and polymorphonuclear cells of at least 90% increase the likelihood of a septic joint.
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.
 
4.0 Follow-up Diagnostic Imaging and Testing Procedures
One diagnostic imaging procedure may provide the same or distinctive information as obtained by other procedures. Therefore, prudent choice of procedure(s) for a single diagnostic procedure, a complementary procedure in combination with other procedures(s), or a proper sequential order in multiple procedures will ensure maximum diagnostic accuracy; minimize adverse effect to patients and cost effectiveness by avoiding duplication or redundancy.
All diagnostic imaging procedures have a significant percentage of specificity and sensitivity for various diagnoses. None is specifically characteristic of a certain diagnosis. Clinical information obtained by history taking and physical examination should be the basis for selection and interpretation of imaging procedure results.
When a diagnostic procedure, in conjunction with clinical information, provides sufficient information to establish an accurate diagnosis, the second diagnostic procedure will become a redundant procedure. At the same time, a subsequent diagnostic procedure can be a complementary diagnostic procedure if the first or preceding procedures, in conjunction with clinical information, cannot provide an accurate diagnosis. Usually, preference of a procedure over others depends upon availability, a patient’s tolerance, and/or the treating practitioner’s familiarity with the procedure.
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.
4.1.1.1 The high field, closed MRI with 1.5 or higher tesla provides better resolution. A lower field scan may be indicated when a patient cannot fit into a high field scanner or is too claustrophobic despite sedation. Inadequate resolution on the first scan may require a second MRI using a different technique or with a reading by a musculoskeletal radiologist. All questions in this regard should be discussed with the MRI center and/or radiologist.
4.1.1.2 MRIs have high sensitivity and specificity for meniscal tears and ligamentous injuries although in some cases when physical exam findings and functional deficits indicate the need for surgery an MRI may not be necessary. MRI is less accurate for articular cartilage defects (sensitivity 76%) than for meniscal and ligamentous injury (sensitivity greater than 90%).
4.1.1.3 MRIs have not been shown to be reliable for diagnosing symptomatic hip bursitis.
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.
4.1.5.1 Bone scanning is more sensitive but less specific than MRI. It is useful for the investigation of trauma, infection, stress fracture, occult fracture, Charcot joint, Complex Regional Pain Syndrome and suspected neoplastic conditions of the lower extremity.
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.
4.2.2.1 DA may also be employed in the treatment of acute joint disorders. In some cases, the mechanism of injury and physical examination findings will strongly suggest the presence of a surgical lesion. In those cases, it is appropriate to proceed directly with the interventional arthroscopy.
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.
4.2.4.1 In general, these diagnostic procedures are complementary to imaging procedures such as CT, MRI, and/or myelography or diagnostic injection procedures. Electrodiagnostic studies may provide useful, correlative neuropathophysiological information that would be otherwise unobtainable from standard radiologic studies.
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.
4.2.5.1 Once a diagnosis consistent with the standards of the American Psychiatric Association Diagnostic Statistical Manual of Mental Disorders has been determined, the patient should be evaluated for the potential need for psychiatric medications. Use of any medication to treat a diagnosed condition may be ordered by the authorized treating physician or by the consulting psychiatrist. Visits for management of psychiatric medications are medical in nature and are not a component of psychosocial treatment. Therefore, separate visits for medication management may be necessary, depending upon the patient and medications selected.
4.2.5.2 The screening or diagnostic workup should have clarified and distinguished between pre-existing, aggravated, and/or purely causative psychological conditions. Therapeutic and diagnostic modalities include, but are not limited to, individual counseling, and group therapy. Treatment can occur within an individualized model, a multi-disciplinary model, or within a structured pain management program.
4.2.5.3 A psychologist with a Ph.D., PsyD, EdD credentials, or a Psychiatric MD/DO may perform psychosocial treatments. Other licensed mental health providers working in consultation with a Ph.D., PsyD, EdD, or Psychiatric MD/DO, and with experience in treating pain management in injured workers may also perform treatment.
4.2.5.4 Frequency: 1 to 5 times weekly for the first 4 weeks (excluding hospitalization, if required), decreasing to 1 to 2 times per week for the second month. Thereafter, 2 to 4 times monthly with the exception of exacerbations which may require increased frequency of visits. Not to include visits for medication management.
4.2.5.5 Maximum duration: 6 to 12 months, not to include visits for medication management. For select patients, longer supervised treatment may be required.
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.
4.3.1.1 Frequency: One time for evaluation. Can monitor improvements in strength every 3 to 4 weeks up to a total of 6 evaluations.
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.
 
5.0 Specific Lower Extremity Injury Diagnosis, Testing, and Treatment
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:
5.1.1.5.1 Initial Treatment: Cast in non weight-bearing for tears. Protected weight-bearing for other injuries.
5.1.1.5.2 Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Section 6.0 Medications and Medical Management.
5.1.1.5.3 Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.
5.1.1.5.4 Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. Eccentric training alone or with specific bracing may be used for tendonopathy. Manual therapy may also be used. Therapy will usually 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 adjacent 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 distal and proximal structures. Refer to Section 6.0, Therapeutic Procedures, Non-operative.
5.1.1.5.4.1 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.
5.1.1.5.5 Steroid injections should generally be avoided in these patients since this is a risk for later rupture.
5.1.1.5.6 Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Section 6.0. 13, Return to Work.
5.1.1.5.7 Other therapies in Section 6.0. Therapeutic Procedures, Non-operative may be employed in individual cases.
5.1.1.5.8 The use of PRP may be beneficial in refractory chronic tendonopathies. Musculoskeletal ultrasound is recommended when performing PRP.
5.1.1.6 Surgical Indications/Considerations: Total or partial rupture.
Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling and medication by the physician.
5.1.1.7 Operative Procedures: Repair of tendons open or percutaneously with or without anchors may be required. Tendon grafts are used for chronic cases or primary surgery failures when tendon tissue is poor.
5.1.1.8 Post-operative Treatment:
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.
5.1.1.8.2 Treatment may include the following: restricted weight-bearing, bracing, active therapy with or without passive therapy.
5.1.1.8.3 Range of motion may begin at 3 weeks depending on wound healing. Therapy and some restrictions will usually continue for 6 to 8 weeks.
5.1.1.8.4 Return to work and restrictions after surgery may be made by an attending physician in consultation with the surgeon or by the surgeon.
5.1.2 Aggravated Osteoarthritis:
5.1.2.1 Description/Definition: Internal joint pathology of ankle.
5.1.2.1.1 Other causative factors to consider: Prior significant injury to the ankle 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 extremity.
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:
5.1.2.4.1 Initial Treatment: May include orthoses, custom shoes with rocker bottom shoe inserts, and braces. Cane may also be useful.
5.1.2.4.2 Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Section 6.0, Medications and Medical Management.
5.1.2.4.3 Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.
5.1.2.4.4 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 adjacent 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 distal and proximal structures. Refer to Section 6.0., Therapeutic Procedures, Non-operative.
5.1.2.4.4.1 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.
5.1.2.4.5 Steroid injections may decrease inflammation and allow the therapist to progress with functional exercise and range of motion. Steroid injections under significant pressure should be avoided as the needle may be penetrating the tendon and injection into the tendon can cause possible tendon breakdown, tendon degeneration, or rupture. Injections should be minimized for patients younger than 30 years of age. 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.
5.1.2.4.5.1 Time to Produce Effect: One injection.
5.1.2.4.5.2 Maximum Duration: 3 injections in one year spaced at least 4 to 8 weeks apart.
5.1.2.4.5.3 Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for 2 weeks after injections.
5.1.2.4.6 Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Section 6.0., the Return to Work subsection.
5.1.2.4.7 Other therapies in Section 6.0, Therapeutic Procedures, Non-operative may be employed in individual cases.
5.1.2.5 Surgical Indications/Considerations:
5.1.2.5.1 The patient is a good surgical candidate and pain continues to interfere with ADLs after non-surgical interventions including weight control, therapy with active patient participation, and medication.
5.1.2.5.2 Refer to Section 7.0 for specific indications for osteotomy, ankle fusion or arthroplasty.
5.1.2.5.3 Implants are less successful than similar procedures in the knee or hip. There are no quality studies comparing arthrodesis and ankle replacement. Patients with ankle fusions generally have good return to function and fewer complications than those with joint replacements. Salvage procedures for ankle replacement include revision with stemmed implant or allograft fusion. Given these factors, an ankle arthroplasty requires prior authorization and a second opinion by a surgeon specializing in lower extremity surgery.
5.1.2.5.4 Prior to surgical intervention, the patient and treating physician should identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work 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.
5.1.2.5.5 In cases where surgery is contraindicated due to obesity, it may be appropriate to recommend a weight loss program if the patient is unsuccessful losing weight on their own. Coverage for weight loss would continue only for motivated patients who have demonstrated continual progress with weight loss.
5.1.2.5.6 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.
5.1.2.6 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:
5.1.2.7.1 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.
5.1.2.7.2 In all cases, communication between the physician and therapist is important to the timing of weight-bearing and exercise progressions.
5.1.2.7.3 Treatment may include the following: restricted weight-bearing, bracing, gait training and other active therapy with or without passive therapy.
5.1.2.7.4 Refer to Section 7.0 for Ankle Fusion, Osteotomy, or Arthroplasty for further specific information.
5.1.2.7.5 Return to work and restrictions after surgery may be made by an attending physician in consultation with the surgeon or by the surgeon.
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:
5.1.3.5.1 Initial Treatment: Closed reduction under anesthesia with pre- and post-reduction neurovascular assessment followed by casting and weight-bearing limitations.
5.1.3.5.2 Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Section 6.0, Medications and Medical Management.
5.1.3.5.3 Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.
5.1.3.5.4 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 adjacent 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 distal and proximal structures. Refer to Section 6.0, Therapeutic Procedures, Non-operative.
5.1.3.5.4.1 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.
5.1.3.5.5 Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Section 6.0, Return to Work.
5.1.3.5.6 Other therapies in Section 6.0, Therapeutic Procedures, Non-operative may be employed in individual cases.
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:
5.1.3.8.1 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.
5.1.3.8.2 Treatment usually includes initial immobilization with restricted weight-bearing, followed by bracing and active therapy with or without passive therapy.
5.1.3.8.3 Return to work and restrictions after surgery may be made by an attending physician in consultation with the surgeon or by the surgeon.
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:
5.1.4.1.1 Grade 1 Injury: those with overstretching or microscopic tears of the ligament, minimal swelling, normal stress testing, and the ability to bear weight.
5.1.4.1.2 Grade 2 Injury: have partial disruption of the ligament, significant swelling, indeterminate results on stress testing, and difficulty bearing weight.
5.1.4.1.3 Grade 3 Injury: have a ruptured ligament, swelling and ecchymosis, abnormal results on stress testing, and the inability to bear weight. May also include a chip avulsion fracture on x-ray.
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.
5.1.4.3.1 Syndesmotic injury can occur with external rotation injuries and requires additional treatment. Specific physical exam tests include the squeeze test and external rotation at neutral.
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%.
5.1.4.4.1 For an acute, unstable ankle or a repeat or chronic ankle injury, a MRI and/or diagnostic injection may be ordered. Arthroscopy can be used in unusual cases with persistent functional instability and giving way of the ankle, after conservative treatment, to directly visualize the ruptured ligament(s).
5.1.4.5 Non-operative Treatment Procedures:
5.1.4.5.1 Initial treatment for patients able to bear weight: NSAIDs, RICE (rest, ice, compression and elevation), and early functional bracing is used. In addition, crutches may be beneficial for comfort. Early functional treatment including range of motion and strengthening exercises along with limited weight-bearing, are preferable to strict immobilization with rigid casting for improving outcome and reducing time to return to work.
5.1.4.5.2 Initial treatment for patients unable to bear weight: bracing plus NSAIDs and RICE are used. When patient becomes able to bear weight a walker boot is frequently employed. There is no clear evidence favoring ten days of casting over pneumatic bracing as initial treatment for patients who cannot bear weight three days post injury. There is good evidence that use of either device combined with functional therapy results in similar long-term recovery.
5.1.4.5.2.1 There is some evidence that functional rehabilitation has results superior to six weeks of immobilization.
5.1.4.5.2.2 Small avulsion fractures of the fibula with minimal or no displacement can be treated as an ankle sprain.
5.1.4.5.2.3 For patients with a clearly unstable joint, immobilize with a short leg plaster cast or splint for 2 to 6 weeks along with early weight-bearing.
5.1.4.5.3 Balance/coordination training is a well-established treatment which improves proprioception and may decrease incidence of recurrent sprains.
5.1.4.5.4 Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Section 6.0, Medications and Medical Management.
5.1.4.5.5 Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.
5.1.4.5.6 Heel wedges or other orthotics may be used for rear foot varus or valgus deformities.
5.1.4.5.6.1 There is good evidence that semi-rigid orthoses or pneumatic braces prevent ankle sprains during high risk physical activities and they should be used as appropriate after acute sprains.
5.1.4.5.7 When fractures are involved refer to comments related to osteoporosis in Section
6.0, Therapeutic Procedures, Non-operative, subsection, Osteoporosis Management.
5.1.4.5.8 Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.
5.1.4.5.9 Return-to-work with appropriate restrictions should be considered early in the course of treatment. Refer to Section 6.0, Return to Work.
5.1.4.5.10 Other therapies in Section 6.0, Therapeutic Procedures, Non-operative, including manual therapy may be employed in individual cases.
5.1.4.5.11 Hyperbaric oxygen therapy is not recommended.
5.1.4.6 Surgical Indications/Considerations:
5.1.4.6.1 Acute surgical indications include sprains with displaced fractures, syndesmotic disruption or ligament sprain associated with a fracture causing instability.
5.1.4.6.2 There is no conclusive evidence that surgery as opposed to functional treatment for an uncomplicated Grade I-III ankle sprain improves patient outcome.
5.1.4.6.3 Chronic indications are functional problems, such as recurrent instability, remaining after at least 2 months of appropriate therapy including active participation in a non-operative therapy program including balance training.
5.1.4.6.4 Prior to surgical intervention, the patient and treating physician should identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work 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.
5.1.4.6.5 If injury is a sprain: Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.
5.1.4.6.6 If injury is a fracture: 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.
5.1.4.7 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:
5.1.4.8.1 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. Treatment may include short-term post surgical casting. In all cases, communication between the physician and therapist is important to the timing of weight-bearing and exercise progressions.
5.1.4.8.1.1 There is some evidence that more rapid recovery occurs with functional rehabilitation compared to six weeks of immobilization in a cast.
5.1.4.8.2 The surgical procedures and the patient’s individual results dictate the amount of time a patient has non weight-bearing restrictions. Fractures usually require 6 to 8 weeks while tendon transfers may be 6 weeks. Other soft tissue repairs, such as the Brostrom lateral ankle stabilization, may be as short as 3 weeks.
5.1.4.8.3 Return to work and restrictions after surgery may be made by an attending physician in consultation with the surgeon or by the surgeon.
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:
5.1.5.5.1 Initial Treatment: Non weight-bearing 6 to 8 weeks, followed by weight-bearing cast at physician’s discretion and active therapy with or without passive therapy.
5.1.5.5.2 Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Section 6.0, the Medications and Medical Management subsection.
5.1.5.5.3 Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.
5.1.5.5.4 Refer to comments related to osteoporosis in Section 6.0, Therapeutic Procedures, Non-operative, Osteoporosis Management.
5.1.5.5.5 Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.
5.1.5.5.6 Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Section 6.0, Return to Work.
5.1.5.5.7 Other therapies in Section 6.0, Therapeutic Procedures, Non-operative may be employed in individual cases.
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.
5.1.5.6.1 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.
5.1.5.7 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.
5.1.5.7.1 Complications may include wound infections requiring skin graft.
5.1.5.8 Post-operative Treatment:
5.1.5.8.1 An individualized rehabilitation program based upon communication between the surgeon and the therapist using the 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.
5.1.5.8.2 The patient is usually non weight-bearing for 6 to 8 weeks followed by weight-bearing for approximately 6 to 8 weeks at physician’s discretion.
5.1.5.8.3 Treatment may include the following: restricted weight-bearing, bracing, active therapy with or without passive therapy.
5.1.5.8.4 Return to work and restrictions after surgery may be made by an attending physician in consultation with the surgeon or by the surgeon.
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:
5.1.6.5.1 Initial Treatment: Acute injuries may require immobilization followed by active therapy with or without passive therapy.
5.1.6.5.2 Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Section 6.0, Medications and Medical Management.
5.1.6.5.3 Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.
5.1.6.5.4 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 adjacent 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 distal and proximal structures. Refer to Section 6.0, Therapeutic Procedures, Non-operative.
5.1.6.5.4.1 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.
5.1.6.5.5 Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Section 6.0, Return to Work.
5.1.6.5.6 Other therapies in Section 6.0, Therapeutic Procedures, Non-operative may be employed in individual cases.
5.1.6.6 Surgical Indications/Considerations:
5.1.6.6.1 Functional deficits not responsive to conservative therapy. Identification of an osteochondral lesion by diagnostic testing procedures should be done to determine the size of the lesion and stability of the joint.
5.1.6.6.2 Microfracture is the initial treatment unless there are other anatomic variants such as a cyst under the bone.
5.1.6.6.3 Osteochondral Autograft Transfer System (OATS) may be effective in patients without other areas of osteoarthritis, a BMI of less than 35 and a failed microfracture. This procedure may be indicated when functional deficits interfere with activities of daily living and/or job duties 6 to 12 weeks after a failed microfracture with active patient participation in non-operative therapy. This procedure is only appropriate in a small subset of patients and requires prior authorization.
5.1.6.6.4 Autologous cartilage cell implant is not FDA approved for the ankle and therefore not recommended.
5.1.6.6.5 Prior to surgical intervention, the patient and treating physician should identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work 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.
5.1.6.6.6 Smoking may affect tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.
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.
5.1.6.8.2 Treatment may include the following: restricted weight-bearing, bracing, active therapy with or without passive therapy.
5.1.6.8.3 Return to work and restrictions after surgery may be made by an attending physician in consultation with the surgeon or by the surgeon.
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:
5.1.7.5.1 Initial Treatment: This condition usually responds to conservative management consisting of eccentric exercise of the gastrocnemius, plantar fascial stretching, taping, soft-tissue mobilization, night splints, and orthotics. Therapy may include passive therapy, taping, and injection therapy.
5.1.7.5.2 Shock absorbing shoe inserts may prevent back and lower extremity problems in some work settings.
5.1.7.5.3 Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Section 6.0, Medications and Medical Management.
5.1.7.5.4 Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.
5.1.7.5.5 Steroid injections may decrease inflammation and allow the therapist to progress with functional exercise and range of motion. Steroid injections under significant pressure should be avoided as the needle may be penetrating the tendon and injection into the tendon can cause possible tendon breakdown, tendon degeneration, or rupture. Injections should be minimized for patients younger than 30 years of age. 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.
5.1.7.5.5.1 Time to Produce Effect: One injection.
5.1.7.5.5.2 Maximum Duration: 3 injections in one year spaced at least 4 to 8 weeks apart.
5.1.7.5.5.3 Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for 2 weeks after injections.
5.1.7.5.6 Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Section 6.0, Return to Work.
5.1.7.5.7 After four months of failed therapy, Extracorporeal Shock Wave Therapy (ESWT) trial may be considered prior to surgery. Refer to Section 6.0, Therapeutic Procedures, Non-operative.
5.1.7.5.8 Other therapies in Section 6.0,Therapeutic Procedures, Non-operative may be employed in individual cases.
5.1.7.6 Surgical Indications/Considerations:
5.1.7.6.1 Surgery is employed only after failure of at least 4 to 6 months of active patient participation in non-operative treatment.
5.1.7.6.2 Indications for a gastrocnemius recession include a positive Silfverskiöld test. This procedure does not weaken the arch as may occur with a plantar fascial procedure, however, there is a paucity of literature on this procedure.
5.1.7.6.3 Prior to surgical intervention, the patient and treating physician should identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work 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.
5.1.7.6.4 Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.
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:
5.1.7.8.1 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.
5.1.7.8.2 Treatment may include the following: restricted weight-bearing, bracing, active therapy with or without passive therapy. Usually non weight-bearing for 7 to 10 days followed by weight-bearing cast or shoe for four weeks; however, depending on the procedure some patients may be restricted from weight-bearing for 4 to 6 weeks.
5.1.7.8.3 Return to work and restrictions after surgery may be made by an attending physician in consultation with the surgeon or by the surgeon.
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:
5.1.8.5.1 Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Section 6.0, Medications and Medical Management.
5.1.8.5.2 Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.
5.1.8.5.3 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 adjacent structures. Passive as well as active therapies may be used for control of pain and swelling. Orthotics and iontophoresis are usually included. A carbon fiber Morton extension may be useful. Therapy should progress to strengthening and an independent home exercise program targeted to further improve ROM, strength, and normal joint mechanics influenced by distal and proximal structures. Refer to Section 6.0, Therapeutic Procedures, Non-operative.
5.1.8.5.3.1 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.
5.1.8.5.4 Steroid injections may decrease inflammation and allow the therapist to progress with functional exercise and range of motion. Steroid injections under significant pressure should be avoided as the needle may be penetrating the tendon and injection into the tendon can cause possible tendon breakdown, tendon degeneration, or rupture. Injections should be minimized for patients younger than 30 years of age.
5.1.8.5.4.1 Time to Produce Effect: One injection.
5.1.8.5.4.2 Maximum Duration: 3 injections in one year spaced at least 4 to 8 weeks apart.
5.1.8.5.4.3 Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for 2 weeks after injections.
5.1.8.5.5 Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Section 6.0, Return to Work.
5.1.8.5.6 Other therapies in Section 6.0, Therapeutic Procedures, Non-operative may be employed in individual cases.
5.1.8.6 Surgical Indications/Considerations:
5.1.8.6.1 Pain, unresponsive to conservative care and interfering with activities of daily living.
5.1.8.6.2 First metatarsal arthritis or avascular necrosis can interfere with function and gait.
5.1.8.6.3 Prior to surgical intervention, the patient and treating physician should identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work 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.
5.1.8.6.4 Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.
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.
5.1.8.7.1 There is some evidence that the first metatarsal-phalangeal joint arthritis is better treated with arthrodesis than arthroplasty for pain and functional improvement. Therefore, total joint arthroplasties are not recommended for any metatarsal-phalangeal joints due to less successful outcomes than fusions. There may be an exception for first and second metatarsal-phalangeal joint arthroplasties when a patient is older than 60, has low activity levels, and cannot tolerate non weight-bearing for prolonged periods or is at high risk for non-union.
5.1.8.7.2 Metallic hemi-arthroplasties are still considered experimental as long-term outcomes remain unknown in comparison to arthrodesis, and there is a significant incidence of subsidence. Therefore, these are not recommended at this time.
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.
5.1.8.8.2 For fusions and osteotomies, reduced weight-bearing and the use of special shoes will be necessary for at least 6 weeks post operative. For other procedures early range-of-motion, bracing, and/or orthotics. Treatment usually also includes other active therapy with or without passive therapy.
5.1.8.8.3 Return to work and restrictions after surgery may be made by an attending physician in consultation with the surgeon or by the surgeon.
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.
5.1.9.3.1 Dislocation may not always be apparent. Pronation and supination of the forefoot with the calcaneus fixed in the examiners opposite hand may elicit pain in a Lisfranc injury, distinguishing it from an ankle sprain, in which this maneuver is expected to be painless. 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 metatarsal, assessing for pain proximally. The dorsalis pedis artery crosses the second metatarsal and may be disrupted. Therefore, the dorsalis pedis pulse and capillary filling should be assessed.
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:
5.1.9.5.1 Initial Treatment: If minimal or no displacement then casting, non weight-bearing 6 to 8 weeks. Orthoses may be used later.
5.1.9.5.2 Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Section 6.0, Medications and Medical Management.
5.1.9.5.3 Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.
5.1.9.5.4 Refer to comments related to osteoporosis in Section 6.0, Therapeutic Procedures, Non-operative, Osteoporosis Management.
5.1.9.5.5 Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.
5.1.9.5.6 Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Section 6.0, Return to Work.
5.1.9.5.7 Other therapies in Section 6.0, Therapeutic Procedures, Non-operative may be employed in individual cases.
5.1.9.6 Surgical Indications/Considerations: Displacement of fragments or intra-articular fracture. Most Lisfranc fracture/dislocations are treated surgically.
5.1.9.6.1 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.
5.1.9.7 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:
5.1.9.8.1 An individualized rehabilitation program based upon communication between the surgeon and the therapist using treatments 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.
5.1.9.8.2 The patient is usually in cast or fracture walker for 6 to 8 weeks non weight-bearing. Orthoses may be indicated after healing.
5.1.9.8.3 Treatment may include the following: restricted weight-bearing, bracing, active therapy with or without passive therapy.
5.1.9.8.4 Return to work and restrictions after surgery may be made by an attending physician in consultation with the surgeon or by the surgeon.
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:
5.1.10.5.1 Initial Treatment: Nonsteroidal anti-inflammatories and foot orthoses are primary treatments.
5.1.10.5.2 Medications such as analgesics and anti-inflammatories are usually helpful. Refer to medication discussions in Section 6.0, Medications and Medical Management.
5.1.10.5.3 Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.
5.1.10.5.4 Steroid injections may decrease inflammation and allow the therapist to progress with functional exercise and range of motion. Steroid injections under significant pressure should be avoided as the needle may be penetrating the tendon and injection into the tendon can cause possible tendon breakdown, tendon degeneration, or rupture. Injections should be minimized for patients younger than 30 years of age.
5.1.10.5.4.1 Time to Produce Effect: One injection.
5.1.10.5.4.2 Maximum Duration: 3 injections in one year spaced at least 4 to 8 weeks apart.
5.1.10.5.4.3 Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for 2 weeks after injections.
5.1.10.5.5 Alcohol injections are thought to produce a chemical neurolysis. Alcohol injection with ultrasound guidance may be used to decrease symptoms.
5.1.10.5.5.1 Optimum Duration: 4 treatments.
5.1.10.5.5.2 Maximum Duration: 7 treatments.
5.1.10.5.6 Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Section 6.0, Return to Work.
5.1.10.5.7 Other therapies in Section 6.0,Therapeutic Procedures, Non-operative may be employed in individual cases.
5.1.10.6 Surgical Indications/Considerations:
5.1.10.6.1 Functional deficits persisting after 2 to 3 months of active participation in therapy.
5.1.10.6.2 Prior to surgical intervention, the patient and treating physician should identify functional operative goals and the likelihood of achieving improved ability to perform activities of daily living or work 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.
5.1.10.6.3 Smoking may affect soft tissue healing through tissue hypoxia. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.
5.1.10.7 Operative Procedures: Excision of the neuroma; nerve transection or transposition.
5.1.10.8 Post-operative Treatment:
5.1.10.8.1 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.
5.1.10.8.2 Treatment may involve a period of non weight-bearing for up to two weeks, followed by gradual protected weight-bearing 4 to 6 weeks.
5.1.10.8.3 Return to work and restrictions after surgery may be made by an attending physician in consultation with the surgeon or by the surgeon.
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:
5.1.11.5.1 Initial Treatment: Prolonged non weight-bearing at physician’s discretion.
5.1.11.5.2 Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Section 6.0, Medications and Medical Management.
5.1.11.5.3 Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.
5.1.11.5.4 Refer to comments related to osteoporosis in Section 6.0, Therapeutic Procedures, Non-operative, Osteoporosis Management.
5.1.11.5.5 Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.
5.1.11.5.6 Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Section 6.0, Return to Work.
5.1.11.5.7 Other therapies in Section 6.0, Therapeutic Procedures, Non-operative may be employed in individual cases.
5.1.11.6 Surgical Indications/Considerations: Displacement of fracture, severe comminution necessitating primary fusion.
5.1.11.6.1 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.
5.1.11.7 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:
5.1.11.8.1 An individualized rehabilitation program based upon communication between the surgeon and the therapist using treatment 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.
5.1.11.8.2 Treatment may include the following: restricted weight-bearing, bracing, active therapy with or without passive therapy.
5.1.11.8.3 Return to work and restrictions after surgery may be made by an attending physician in consultation with the surgeon or by the surgeon.
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.
5.1.12.3 Specific Physical Exam Findings: Painful posterior tibial tendon with active and passive non weight-bearing motion, reproduction of pain with forced plantar flexion and inversion of the ankle, difficulty performing single heel raise, pain with palpation from the posterior medial foot along the medial malleous to the navicular greater tuberosity. The patient should also be evaluated for a possible weak gluteus medius as a contributing factor.
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:
5.1.12.5.1 Initial Treatment: Short ankle articulated orthosis and therapy including low-load strengthening exercises with progression to home program. Other active and passive therapy including iontophoresis, orthotics and possible strengthening for the gluteus medius.
5.1.12.5.2 Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Section 6.0, Medications and Medical Management.
5.1.12.5.3 Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.
5.1.12.5.4 Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Section 6.0, Return to Work.
5.1.12.5.5 Other therapies in Section 6.0, Therapeutic Procedures, Non-operative may be employed in individual cases.
5.1.12.6