La. Admin. Code tit. 40 § I-2309

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-2309 - Specific Lower Extremity Injury Diagnosis, Testing, and Treatment

1. Foot and Ankle

a. Achilles Tendonopathy/or Injury and Rupture (ALTERNATE SPELLING: "TENDINOPATHY"):

i. Description/Definition: Rupture or tear of Achilles tendon or insertional or non-insertional tendonopathy.

ii. Occupational Relationship: 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.

iii. 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.

iv. 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.

v. Non-operative Treatment Procedures:

(a). Initial Treatment: Cast in non weight-bearing for tears. Protected weight-bearing for other injuries.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). 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 Therapeutic Procedures, Non-operative.

(i). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found in Therapeutic Procedures, Non-operative.

(e). Steroid injections should generally be avoided in these patients since this is a risk for later rupture.

(f). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(g). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations: Total or partial rupture.

(a). 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.

vii. 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.

viii. Post-operative Treatment:

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist using therapies as outlined in Section F, Therapeutic Procedures, Non-operative.

(b). Treatment may include the following: restricted weight-bearing, bracing, active therapy with or without passive therapy.

(c). Range of motion may begin at three weeks depending on wound healing. Therapy and some restrictions will usually continue for six to eight weeks.

(d). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

b. Aggravated Osteoarthritis:

i. Description/Definition: Internal joint pathology of ankle.

ii. Occupational Relationship: The provider must establish the occupational relationship by establishing a change in the patient's baseline condition and a relationship to work activities, for example frequent jumping, climbing, or squatting.

(a). 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 two 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.

iii. Specific Physical Exam Findings: Pain within joint, swelling. Crepitus, locking of the joint, reduced range of motion, pain with stress tests, angular deformities.

iv. Diagnostic Testing Procedures: X-ray mechanical axis views, CT, MRI, diagnostic injection.

v. Non-operative Treatment Procedures:

(a). Initial Treatment: May include orthoses, custom shoes with rocker bottom shoe inserts, and braces. Cane may also be useful.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). 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 Therapeutic Procedures, Non-operative.

(i). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found in Therapeutic Procedures, Non-operative.

(e). 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 under 30 years of age.

(i). Time to Produce Effect: One injection.

(ii). Maximum Duration: Three injections in one year spaced at least four to eight weeks apart.

(iii). Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for two weeks after injections.

(f). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(g). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations:

(a). 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.

(b). Refer to Therapeutic Procedures-Operative, for specific indications for osteotomy, ankle fusion or arthroplasty.

(c). 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.

(d). 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.

(e). 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.

(f). 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.

vii. 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.

viii. Post-operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist using therapies as outlined in Section F, Therapeutic Procedures, Non-operative.

(b). In all cases, communication between the physician and therapist is important to the timing of weight-bearing and exercise progressions.

(c). Treatment may include the following: restricted weight-bearing, bracing, gait training and other active therapy with or without passive therapy.

(d). Refer to Ankle Fusion, Osteotomy, or Arthroplasty for further specific information.

(e). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

c. Ankle or Subtalar Joint Dislocation:

i. Description/Definition: Dislocation of ankle or subtalar joint.

ii. Occupational Relationship: Usually occurs with falling or twisting.

iii. Specific Physical Exam Findings: Disruption of articular arrangements of ankle, subtalar joint may be tested using ligamentous laxity tests.

iv. 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.

v. Non-operative Treatment Procedures:

(a). Initial Treatment: Closed reduction under anesthesia with pre- and post-reduction neurovascular assessment followed by casting and weight-bearing limitations.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). 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 Therapeutic Procedures, Non-operative.

(i). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found in Therapeutic Procedures, Non-operative.

(e). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(f). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations: Inability to reduce closed fracture, association with unstable fractures

vii. Operative Procedures: Open or closed reduction of dislocation.

viii. Post-operative Treatment:

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist using therapies as outlined in Therapeutic Procedures, Non-operative.

(b). Treatment usually includes initial immobilization with restricted weight-bearing, followed by bracing and active therapy with or without passive therapy.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

d. Ankle Sprain/Fracture

i. 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:

(a). Grade 1 Injury: those with overstretching or microscopic tears of the ligament, minimal swelling, normal stress testing, and the ability to bear weight.

(b). Grade 2 Injury: have partial disruption of the ligament, significant swelling, indeterminate results on stress testing, and difficulty bearing weight.

(c). 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.

ii. Occupational Relationship: sudden twisting, direct blunt trauma and falls. Inversion of the ankle with a plantar-flexed foot is the most common mechanism of injury.

iii. 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.

(a). 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.

iv. 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 percent and a modest specificity, and its use should reduce the number of unnecessary radiographs by 30 to 40 percent.

(a). 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).

v. Non-operative Treatment Procedures

(a). 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.

(b). 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.

(i). There is some evidence that functional rehabilitation has results superior to six weeks of immobilization.

(ii). Small avulsion fractures of the fibula with minimal or no displacement can be treated as an ankle sprain.

(iii). For patients with a clearly unstable joint, immobilize with a short leg plaster cast or splint for two to six weeks along with early weight-bearing.

(c). Balance/coordination training is a well-established treatment which improves proprioception and may decrease incidence of recurrent sprains.

(d). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(e). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(f). Heel wedges or other orthotics may be used for rear foot varus or valgus deformities.

(i). 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.

(g). When fractures are involved refer to comments related to osteoporosis in Therapeutic Procedures, Non-operative, Osteoporosis Management.

(h). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.

(i). Return-to-work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(j). Other therapies in Therapeutic Procedures, Non-operative, including manual therapy may be employed in individual cases.

(k). Hyperbaric oxygen therapy is not recommended.

vi. Surgical Indications/Considerations:

(a). Acute surgical indications include sprains with displaced fractures, syndesmotic disruption or ligament sprain associated with a fracture causing instability.

(b). There is no conclusive evidence that surgery as opposed to functional treatment for an uncomplicated Grade I-III ankle sprain improves patient outcome.

(c). 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.

(e). 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.

(f). 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.

vii. Operative Treatment: Repair of fractures or other acute pathology as necessary. Primary ligament ankle reconstruction with possible tendon transplant.

viii. Post-operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist using therapies as outlined in 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.

(i). There is some evidence that more rapid recovery occurs with functional rehabilitation compared to six weeks of immobilization in a cast.

(b). The surgical procedures and the patient's individual results dictate the amount of time a patient has non weight-bearing restrictions. Fractures usually require six to eight weeks while tendon transfers may be six weeks. Other soft tissue repairs, such as the Brostrom lateral ankle stabilization, may be as short as three weeks.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

e. Calcaneal Fracture:

i. Description/Definition: Osseous fragmentation/separation confirmed by diagnostic studies.

ii. Occupational Relationship: Usually occurs by fall or crush injury.

iii. 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.

iv. 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.

v. Non-operative Treatment Procedures:

(a). Initial Treatment: Non weight-bearing six to eight weeks, followed by weight-bearing cast at physician's discretion and active therapy with or without passive therapy.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). Refer to comments related to osteoporosis in Therapeutic Procedures, Non-operative, Osteoporosis Management.

(e). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.

(f). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(g). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. 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.

(a). 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.

vii. 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.

(a). Complications may include wound infections requiring skin graft.

viii. Post-operative Treatment:

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist using the therapies as outlined in Section F, Therapeutic Procedures, Non-operative. In all cases, communication between the physician and therapist is important to the timing of weight-bearing and exercise progressions.

(b). The patient is usually non weight-bearing for six to eight weeks followed by weight-bearing for approximately six to eight weeks at physician's discretion.

(c). Treatment may include the following: restricted weight-bearing, bracing, active therapy with or without passive therapy.

(d). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

f. Chondral and Osteochondral Defects:

i. Description/Definition: Cartilage or cartilage and bone defect of the talar surface. May be associated with ankle sprain or other injuries.

ii. Occupational Relationship: Usually caused by a traumatic ankle injury.

iii. Specific Physical Exam Findings: Ankle effusion, pain in joint and with walking.

iv. Diagnostic Testing Procedures: MRI may show bone bruising, osteochondral lesion, or possibly articular cartilage injury. Radiographs, contrast radiography, CT may also be used.

v. Non-Operative Treatment Procedures:

(a). Initial Treatment: Acute injuries may require immobilization followed by active therapy with or without passive therapy.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(i). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found in Therapeutic Procedures, Non-operative.

(e). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(f). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations

(a). 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.

(b). Microfracture is the initial treatment unless there are other anatomic variants such as a cyst under the bone.

(c). 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..

(d). Autologous cartilage cell implant is not FDA approved for the ankle and therefore not recommended.

(e). 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.

(f). 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.

vii. Operative Procedures: Arthroscopy with debridement or shaving of cartilage, microfracture, mosiacplasty, fixation of loose osteochondral fragments.

viii. Post-operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist and using therapies as outlined in Therapeutic Procedures, Non-operative. In all cases, communication between the physician and therapist is important to the timing of weight-bearing and exercise progressions.

(b). Treatment may include the following: restricted weight-bearing, bracing, active therapy with or without passive therapy.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

g. Heel Spur Syndrome/Plantar Fasciitis:

i. 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.

ii. Occupational Relationship: 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.

iii. 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 Silfverskiold 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.

iv. 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.

v. Non-operative Treatment Procedures:

(a). 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.

(b). Shock absorbing shoe inserts may prevent back and lower extremity problems in some work settings.

(c). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(d). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(i). Time to Produce Effect: One injection.

(ii). Maximum Duration: Three injections in one year spaced at least four to eight weeks apart.

(iii). Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for two weeks after injections.

(f). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(g). After four months of failed therapy, Extracorporeal Shock Wave Therapy (ESWT) trial may be considered prior to surgery. Refer to Therapeutic Procedures, Non-operative.

(h). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations:

(a). Surgery is employed only after failure of at least four to six months of active patient participation in non-operative treatment.

(b). Indications for a gastrocnemius recession include a positive Silfverskiold 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.

(c). 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.

(d). 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.

vii. Operative Treatment Procedures: Plantar fascial release with or without calcaneal spur removal, endoscopic or open gastrocnemius recession.

viii. Post-operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist using therapies as outlined in Therapeutic Procedures, Non-operative.

(b). 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 four to six weeks.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

h. Metatarsal-Phalangeal, Tarsal-Metatarsal and Interphalangeal Joint Arthropathy:

i. Description/Definition: Internal derangement of joint.

ii. Occupational Relationship: Jamming, contusion, crush injury, repetitive impact, or post-traumatic arthrosis.

iii. 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.

iv. Diagnostic Testing Procedures. Radiographs, diagnostic joint injection, CT, MRI.

v. Non-operative Treatment Procedures

(a). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(b). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(c). 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 Therapeutic Procedures, Non-operative.

(i). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found in Therapeutic Procedures, Non-operative.

(d). 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 under 30 years of age.

(i). Time to Produce Effect: One injection.

(ii). Maximum Duration: Three injections in one year spaced at least four to eight weeks apart.

(iii). Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for two weeks after injections.

(e). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(f). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations

(a). Pain, unresponsive to conservative care and interfering with activities of daily living.

(b). First metatarsal arthritis or avascular necrosis can interfere with function and gait.

(d). 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.

vii. 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.

(a). 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.

(b). 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.

viii. Post-Operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist using therapies as outlined in Therapeutic Procedures, Non-operative. In all cases, communication between the physician and therapist is important to the timing of weight-bearing and exercise progressions.

(b). For fusions and osteotomies, reduced weight-bearing and the use of special shoes will be necessary for at least ix 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.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

i. Midfoot (Lisfranc) Fracture/Dislocation

i. Description/Definition: Fracture/ligamentous disruption of the tarsal-metatarsal joints, i.e., metatarsal-cuneiform and metatarsal-cuboid bones.

ii. Occupational Relationship: Usually occurs from a fall, crush, axial load with a plantar flexed foot, or abductory force on the forefoot.

iii. 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.

(a). 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.

iv. Diagnostic Testing Procedures: X-rays, CT scans, MRI, mid-foot stress x-rays.

v. Non-operative Treatment Procedures:

(a). Initial Treatment: If minimal or no displacement then casting, non weight-bearing six to eight weeks. Orthoses may be used later.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). Refer to comments related to osteoporosis in Therapeutic Procedures, Non-operative, Osteoporosis Management.

(e). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.

(f). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(g). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations: Displacement of fragments or intra-articular fracture. Most Lisfranc fracture/dislocations are treated surgically.

vii. Operative Procedures: Open reduction internal fixation with possible removal of hardware at approximately three to six months, pending healing status. Alternatively, arthrodesis of the medial two or three metatarsals.

viii. Post-Operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist using treatments as outlined in Therapeutic Procedures, Non-operative. In all cases, communication between the physician and therapist is important to the timing of weight-bearing and exercise progressions.

(b). The patient is usually in cast or fracture walker for six to eight weeks non weight-bearing. Orthoses may be indicated after healing.

(c). Treatment may include the following: restricted weight-bearing, bracing, active therapy with or without passive therapy.

(d). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

j. Morton's Neuroma

i. 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.

ii. 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.

iii. 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.

iv. 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.

v. Non-operative Treatment Procedures

(a). Initial Treatment: Nonsteroidal anti-inflammatories and foot orthoses are primary treatments.

(b). Medications such as analgesics and anti-inflammatories are usually helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(i). Time to Produce Effect: One injection.

(ii). Maximum Duration: Three injections in one year spaced at least four to eight weeks apart.

(iii). Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for two weeks after injections.

(e). Alcohol injections are thought to produce a chemical neurolysis. Alcohol injection with ultrasound guidance may be used to decrease symptoms.

(i). Optimum Duration: Four treatments.

(ii). Maximum Duration: Seven treatments.

(f). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(g). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations:

(a). Functional deficits persisting after two to three months of active participation in therapy.

(b). 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.

(c). 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.

vii. Operative Procedures: Excision of the neuroma; nerve transection or transposition.

viii. Post-Operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist using therapies as outlined in Therapeutic Procedures, Non-operative.

(b). Treatment may involve a period of non weight-bearing for up to two weeks, followed by gradual protected weight-bearing four to six weeks.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

k. Pilon Fracture

i. Description/Definition: Crush/comminution fracture of distal metaphyseal tibia that has intra-articular extensions into the weight-bearing surface of the tibio-talar joint.

ii. Occupational Relationship: Usually from a fall.

iii. Specific Physical Exam Findings: Swelling, pain with weight-bearing, ecchymosis, and palpable tenderness.

iv. Diagnostic Testing Procedures: Radiographs, CT scans.

v. Non-operative Treatment Procedures

(a). Initial Treatment: Prolonged non weight-bearing at physician's discretion.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). Refer to comments related to osteoporosis in Therapeutic Procedures, Non-operative, Osteoporosis Management.

(e). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.

(f). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(g). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations: Displacement of fracture, severe comminution necessitating primary fusion.

(a). 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.

vii. Operative Procedures: Open reduction internal fixation, fusion, external fixation. In some cases staged procedures may be necessary beginning with external fixation.

viii. Post-operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist using treatment as outlined in Therapeutic Procedures, Non-operative. In all cases, communication between the physician and therapist is important to the timing of weight-bearing and exercise progressions.

(b). Treatment may include the following: restricted weight-bearing, bracing, active therapy with or without passive therapy.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

l. Posterior Tibial Tendon Dysfunction

i. Description/Definition: Pain in the posteromedial ankle with plantar flexion.

ii. Occupational Relationship: Repetitive or forced plantar flexion after an ankle sprain or athletic activity.

iii. 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.

iv. Diagnostic Testing Procedures: X-ray, MRI may be used to rule out other diagnoses.

v. Non-operative Treatment Procedures:

(a). 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.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(e). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations:

(a). Failure of non-operative treatment. Surgery is rarely necessary as success rate for non-operative treatment is around 90 percent.

(c). 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.

vii. Operative Procedures: Resection of anomolous muscle segments or tenolysis. In severe cases, tendon transfer, osteotomies and/or arthrodesis may be necessary.

viii. Post-operative Treatment:

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist and using therapies as outlined in Therapeutic Procedures, Non-Operative.

(b). Treatment may include the following: restricted weight-bearing, bracing, active therapy with or without passive therapy.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

m. Puncture Wounds of the Foot

i. Description/Definition: Penetration of skin by foreign object.

ii. Occupational Relationship: Usually by stepping on foreign object, open wound.

iii. Specific Physical Exam Findings: Site penetration by foreign object consistent with history. In early onset, may show classic signs of infection.

iv. Diagnostic Testing Procedures: X-ray, MRI, ultrasound.

v. Non-operative Treatment Procedures

(a). Initial Treatment: Appropriate antibiotic therapy, tetanus toxoid booster, non weight-bearing at physician's discretion.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(e). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations: Cellulitis, retained foreign body suspected, abscess, compartmental syndrome, and bone involvement.

(a). 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.

vii. Operative Procedures: Incision and drainage with cultures.

viii. Post-operative Treatment

(a). Patient is usually non-weight-bearing with antibiotic therapy based upon cultures. Follow-up x-rays and/or MRI may be needed to evaluate for osseous involvement.

(b). An individualized rehabilitation program based upon communication between the surgeon and the therapist using treatment as outlined in Therapeutic Procedures, Non-operative.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

n. Severe Soft Tissue Crush Injuries:

i. Description/Definition: Soft tissue damage to the foot.

ii. Occupational Relationship: Crush injury or heavy impact to the foot or ankle.

iii. Specific Physical Exam Findings: Pain and swelling over the foot.

iv. Diagnostic Testing Procedures: X-ray and other tests as necessary to rule out other possible diagnoses such as compartment syndrome which requires emergent compartment pressure assessment.

v. Non-operative Treatment Procedures:

(a). Initial Treatment: Usually needs initial rest from work with foot elevation and compression wraps.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(i). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found in Therapeutic Procedures, Non-operative.

(e). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(f). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations: If compartmental pressures are elevated, emergent fasciotomy is warranted.

(a). 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.

vii. Operative Procedures: Emergency fasciotomy. In some cases a delayed primary closure is necessary.

viii. Post-operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist and using therapies as outlined in Section F, Therapeutic Procedures, Non-operative.

(b). Treatment may include the following: elevation, restricted weight-bearing, active therapy with or without passive therapy.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

o. Stress Fracture

i. Description/Definition: Fracture without displacement usually to metatarsals, talus, navicular or calcaneus.

ii. Occupational Relationship: May be related to repetitive, high impact walking; running; or jumping.

iii. Specific Physical Exam Findings: Pain over the affected bone with palpation or weight-bearing.

iv. Diagnostic Testing Procedures: X-ray, CT, MRI, bone scan

v. Non-Operative Treatment Procedures

(a). Initial Treatment: Immobilization for four to eight weeks with limited weight-bearing may be appropriate.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). Refer to comments related to osteoporosis in Therapeutic Procedures, Non-operative, Osteoporosis Management.

(e). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.

(f). There is some evidence that shock absorbing boot inserts may decrease the incidence of stress fractures in military training. Shock absorbing boot inserts of other orthotics may be used in some cases after a stress fracture has occurred or to prevent stress fractures in appropriate work settings.

(g). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(h). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations: Fractures that have not responded to conservative therapy.

vii. Operative Procedures: Most commonly percutaneous screws or plate fixation.

viii. Post-operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist and using therapies as outlined in Section F, Therapeutic Procedures, Non-operative. In all cases, communication between the physician and therapist is important to the timing of weight-bearing and exercise progressions.

(b). Treatment may include the following: restricted weight-bearing, bracing, active therapy with or without passive therapy.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

p. Talar Fracture

i. Description/Definition: Osseous fragmentation of talus confirmed by radiographic, CT or MRI evaluation.

ii. Occupational Relationship: Usually occurs from a fall or crush injury.

iii. Specific Physical Exam Findings: Clinical findings consistent with fracture of talus: pain with range of motion, palpation, swelling, ecchymosis. Pain with weight-bearing attempt.

iv. Diagnostic Testing Procedures: Radiographs, CT scans, MRI. CT scans preferred for spatial alignment.

v. Non-Operative Treatment Procedures

(a). Initial Treatment: Non weight-bearing for six to eight weeks for non-displaced fractures.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). Refer to comments related to osteoporosis in Therapeutic Procedures, Non-operative, Osteoporosis Management.

(e). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.

(f). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(g). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations: Osseous displacement, joint involvement and instability.

vii. Operative Procedures: Open reduction internal fixation.

viii. Post-operative Treatment

(b). Treatment may include the following: Non weight-bearing six to eight weeks followed by weight-bearing cast. MRI follow-up if avascular necrosis is suspected. Active therapy with or without passive therapy.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

q. Tarsal Tunnel Syndrome

i. Description: Pain and paresthesias along the medial aspect of the ankle and foot due to nerve irritation and entrapment of the tibial nerve or its branches. These symptoms can also be caused by radiculopathy.

ii. Occupational Relationship: Acute injuries may occur after blunt trauma along the medial aspect of the foot. Non-traumatic occurrences are determined at physician's discretion after review of environmental and biomechanical risk factors. Non work related causes include space occupying lesions.

iii. Specific Physical Exam Findings: Positive Tinel's sign. Pain with percussion of the tibial nerve radiating distally or proximally. Pain and paresthesias with weight-bearing activities.

iv. Diagnostic Testing Procedures: Nerve conduction velocity studies of both sides for comparison to normal side. EMGs may be needed to rule out radiculopathy. MRI to rule out space occupying lesions. Diagnostic injections to confirm the diagnosis.

v. Non-operative Treatment Procedures:

(a). Initial Treatment: Cast or bracing, immobilization and foot orthoses are appropriate initial management.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). Return to work with appropriate restrictions should be considered early in the course of treatment.

(i). Orthotics or accommodative footwear is usually necessary before workers can be returned to walking on hard surfaces. Refer to Return to Work.

(e). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations

(a). Continued functional deficits after active participation in therapy for three to six months.

(c). 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.

vii. Operative Procedures: Tarsal tunnel release with or without a plantar fascial release.

viii. Post-operative Treatment:

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist and using therapies as outlined in Therapeutic Procedures, Non-Operative.

(b). Treatment may include the following: restricted weight-bearing, orthotics, bracing, active therapy with or without passive therapy.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

r. Tendonopathy: For Achilles Tendonopathy, Refer to Specific Lower Extremity Injury Diagnosis, Testing and Treatment for other types of tendonopathy of the foot and ankle, General recommendations can be found in Tendonopathy of the Knee.

2. Knee

a. Aggravated Osteoarthritis

i. Description/Definition: Swelling and/or pain in a joint due to an aggravating activity in a patient with pre-existing degenerative change in a joint. Age greater than 50 and morning stiffness lasting less than 30 minutes are frequently associated. The lifetime risk for symptomatic knee arthritis is probably around 45 percent and is higher among obese persons.

ii. Occupational Relationship: The provider must establish the occupational relationship by establishing a change in the patient's baseline condition and a relationship to work activities including but not limited to physical activities such as repetitive kneeling or crawling, squatting and climbing, or heavy lifting.

(a). Other causative factors to consider - Previous meniscus or ACL damage may predispose a joint to degenerative changes. In order to entertain previous trauma as a cause, the patient should have medical documentation of the following: menisectomy; hemarthrosis at the time of the original injury; or evidence of MRI or arthroscopic meniscus or ACL damage. The prior injury should have been at least two years from the presentation for the new complaints and there should be a significant increase of pathology on the affected side in comparison to the original imaging or operative reports and/or the opposite un-injured side or extremity.

(b). Body mass index (BMI) of 25 or greater is a significant risk factor for eventual knee replacement.

iii. Specific Physical Exam Findings: Increased pain and/or swelling in a joint with joint line tenderness; joint crepitus; and/or joint deformity.

iv. Diagnostic Testing Procedures: Radiographs, The Kellgren-Lawrence Scale is the standard radiographic scale for knee osteoarthritis. It is based on the development of osteophytes, on bone sclerosis, and on joint space narrowing. The degree of joint space narrowing may not predict disability.

(a). Grade 1: doubtful narrowing of joint space, and possible osteophytic lipping.

(b). Grade 2: definite osteophytes, definite narrowing of joint space.

(c). Grade 3: moderate multiple osteophytes, definite narrowing of joint space, some sclerosis and possible deformity of bone contour.

(d). Grade 4: large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone contour.

(e). MRI to rule out degenerative menisci tears. MRI may identify bone marrow lesions which are correlated with knee pain. These lesions may reflect increased water, blood, or other fluid inside bone and may contribute to the causal pathway of pain. These are incidental findings and should not be used to determine a final diagnosis nor make decisions regarding surgery.

v. Non-Operative Treatment Procedures

(a). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(b). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management. There is good evidence for self-management using weight loss, exercise, pacing of activities, unloading the joint with braces, insoles and possibly taping, and medications as needed. Patients should be encouraged to perform aerobic activity such as walking or biking. However, activities such as ladders, stairs and kneeling may be restricted.

(c). Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. They should include range-of-motion (ROM), active therapies, and a home exercise program. Active therapies include, proprioception training, restoring normal joint mechanics, and clearing dysfunctions from distal to proximal structures. Passive as well as active therapies may be used for control of pain and swelling. Therapy should progress to strengthening and an independent home exercise program targeted to further improve ROM, strength, and normal joint mechanics influenced by structures distal and proximal to the knee. Bracing may be appropriate in some instances. Refer to Therapeutic Procedures, Non-operative. There is good evidence that there is a small functional advantage for patients involved in exercise with physical therapy supervision over home exercise.

(i). There is some evidence that active physical therapy improves knee function more effectively than medication alone.

(ii). Aquatic therapy may be used as a type of active intervention when land-based therapy is not well-tolerated.

(iii). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found in Therapeutic Procedures, Non-operative. There is some evidence that ice massage can improve ROM, strengthening of the knee and function. Ice can be used with proper instruction at home or under supervision for up to 20 minute periods 3 times per week or more frequently.

(d). Therapeutic Injections - both steroids and viscosupplementation may be used.

(i). There is good evidence that intra-articular corticosteroid injection is more effective than placebo in reducing pain from osteoarthritis. Optimum dosage is not known.

(ii). Steroid injections may decrease inflammation and allow the therapist to progress with functional exercise and ROM.

[a]. Time to Produce Effect: One injection.

[b]. Maximum Duration: Three injections in one year at least four to eight weeks apart.

(iii). Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for two weeks after injections.

(iv). Viscosupplementation appears to have a longer lasting effect than intra-articular corticosteroids, however, the overall effect varies depending on the timing and the effect studied. Refer to Therapeutic Procedures.

(e). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(f). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

(g). Bracing such as knee immobilizer or hinge brace may be used for acute ACL injuries.

vi. Surgical Indications/Considerations.

(a). Arthroscopic Debridement and/or Lavage. There is good evidence from a randomized controlled trial that arthroscopic debridement alone provides no benefit over recommended therapy for patients with uncomplicated Grade 2 or higher arthritis. The comparison recommended treatment in the study followed the American College of Rheumatology guidelines which includes: patient education, and supervised therapy with a home program, instruction on ADLs, stepwise use of analgesics and hyaluronic acid injections if desired. Complicated arthritic patients excluded from the study included patients who required other forms of intervention due to the following associated conditions: large meniscal bucket handle tears, inflammatory or infectious arthritis, more than 5 degrees of varus or valgus deformity, previous major knee trauma, or Grade 4 arthritis in two or more compartments.

(i). Therefore, arthroscopic debridement and/or lavage are not recommended for patients with arthritic findings and continual pain and functional deficits unless there is meniscal or cruciate pathology. Refer to the specific conditions in Specific Lower Extremity Injury Diagnosis, Testing and Treatment, for specific diagnostic recommendations.

(b). Osteotomy and joint replacement are indicated when conservative treatment, including active participation in non-operative treatment has failed to result in sufficient functional improvement (Refer to Knee Arthroplasty, and Osteotomy). Tibial osteotomy is a choice for younger patients with unicompartmental disease who have failed conservative therapy.

(c). 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.

(e). 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.

vii. Operative Procedures: Total or compartmental joint replacement, and osteotomy.

(a). Free-floating interpositional unicompartmental replacement is not recommended for any patients due to high revision rate at two years and less than optimal pain relief.

viii. Post-Operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and therapist and using the treatments found in Therapeutic Procedures, Non-operative. In all cases, communication between the physician and therapist is important to the timing of weight-bearing and exercise progressions.

(b). Refer also to Knee Arthroplasty, or Osteotomy as appropriate.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

b. Anterior Cruciate Ligament (ACL) Injury

i. Description/Definition: Rupture or partial rupture of the anterior cruciate ligament; may be associated with other internal derangement of the knee.

ii. Occupational Relationship: May be caused by virtually any traumatic force to the knee but most often caused by a twisting or a hyperextension force, with a valgus stress. The foot is usually planted and the patient frequently experiences a "popping" feeling.

iii. Specific Physical Exam Findings: Findings on physical exam include effusion or hemarthrosis, instability, positive Lachman's test, positive pivot shift test, and positive anterior drawer test.

iv. Diagnostic Testing Procedures: MRI. Radiographs may show avulsed portion of tibial spine but this is a rare finding.

v. Non-operative Treatment Procedures:

(a). Initial Treatment: Acute injuries may require immobilization followed by active therapy with or without passive therapy.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. They should include range-of-motion (ROM), active therapies, and a home exercise program. Active therapies include proprioception training, restoring normal joint mechanics, and clearing dysfunctions from distal and proximal structures bracing may be beneficial. Passive as well as active therapies may be used for control of pain and swelling. Therapy should progress to strengthening and an independent home exercise program targeted to further improve ROM, strength, and normal joint mechanics influenced by structures distal and proximal to the knee (Refer to Therapeutic Procedures, Non-operative). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found in Therapeutic Procedures, Non-operative.

(i). There is no evidence that any particular exercise regime is better for ACL injuries in combination with collateral or meniscus injuries. There is no evidence that knee bracing for non operated ACL improves outcomes although patients may feel that they have greater stability. Non surgical treatment may provide acceptable results in some patients.

(e). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(f). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

iv. Surgical Indications/Considerations: any individual with complaints of recurrent instability interfering with function and physical findings with imaging consistent with an ACL injury.

(a). 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.

(b). 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.

v. Operative Procedures

(a). Diagnostic/surgical arthroscopy followed by ACL reconstruction using autograft or allograft. If meniscus repair is performed, an ACL repair should be performed concurrently.

(b). Patients tend to have more pain associated with patellar grafts while patients with hamstring replacement seem to have an easier rehabilitation. Choice of graft is made by the surgeon and patient on an individual basis.

vi. Post-Operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist and using therapies as outlined in Therapeutic Procedures, Non-operative.

(b). Treatment may include the following: active therapy with or without passive therapy and bracing. Early active extension does not cause increased laxity at two years.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

c. Bursitis of the Lower Extremity

i. Description/Definition: Inflammation of bursa tissue. Bursitis can be precipitated by tendonitis, bone spurs, foreign bodies, gout, arthritis, muscle tears, or infection.

ii. Occupational Relationship: Soft tissue trauma, contusion, or physical activities of the job such as sustained direct compression force, or other repetitive forceful activities affecting the knee.

iii. Specific Physical Exam Findings: Palpable, tender and enlarged bursa, decreased ROM, warmth. The patient may have increased pain with ROM.

iv. Diagnostic Testing Procedures: Lab work may be done to rule out inflammatory disease. Bursal fluid aspiration with testing for connective tissue, rheumatic disease, and infection may be necessary. Radiographs, CT, MRI are rarely indicated.

v. Non-operative Treatment Procedures

(a). Initial Treatment: Diagnostic/therapeutic aspiration, ice, therapeutic injection, treatment of an underlying infection, if present. Aspirations may be repeated as clinically indicated.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. They should include range-of-motion (ROM), active therapies, including a home exercise program. Active therapies include, proprioception training, restoring normal joint mechanics, and clearing dysfunctions from distal and proximal joints. Passive as well as active therapies may be used for control of pain and swelling. Therapy should progress to strengthening and an independent home exercise program targeted to further improve ROM, strength, and normal joint mechanics influenced by structures distal and proximal to the knee. Refer to Therapeutic Procedures, Non-operative.

(i). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found as adjunctive in Therapeutic Procedures, Non-operative.

(e). Steroid Injections. Steroid injections may decrease inflammation and allow the therapist to progress with functional exercise and ROM.

(i). Time to Produce Effect: One injection.

(ii). Maximum Duration: Three injections in one year spaced at least four to eight weeks apart.

(iii). Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for two weeks after injections.

(f). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(g). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical indications/Considerations:

(a). Failure of conservative therapy.

(c). 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.

vii. Operative Procedures: Surgical excision of the bursa.

viii. Post-operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist and using the therapies as outlined in Therapeutic Procedures, Non-operative.

(b). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

d. Chondral and Osteochondral Defects

i. Description/Definition: Cartilage or cartilage and bone defect at the articular surface of a joint. Deficits may be identified in up to 60 percent of arthroscopies; however, only around 30 percent of these lesions are isolated deficits and even fewer are Grade III or IV deficits which might qualify for cartilage grafts.

(a). Defects in cartilage and bone are common at the femoral condyles and patella. The Outerbridge classification grades these defects according to their size and depth.

(i). Grade 0: normal cartilage.

(ii). Grade I: softening and swelling of cartilage.

(iii). Grade II: partial-thickness defects with surface fissures that do not exceed 1.5 cm in diameter and do not reach subchondral bone.

(iv). Grade III: fissuring that reaches subchondral bone in an area with a diameter greater than 1.5 cm.

(v). Grade IV: exposed subchondral bone.

ii. Occupational Relationship: Typically caused by a traumatic knee injury. Chondral deficits can also be present secondary to osteoarthritis.

iii. Specific Physical Exam Findings: Knee effusion, joint line tenderness.

iv. Diagnostic Testing Procedures: MRI may show bone bruising, osteochondral lesion, or possibly articular cartilage injury. Radiographs, contrast radiography, CT may also be used. Diagnostic arthroscopy may be performed when surgical indications as stated in Section VI are met.

v. Non-Operative Treatment Procedures:

(a). Initial Treatment: Non-operative treatment may be indicated for chondral lesions associated with degenerative changes, refer to aggravated osteoarthritis; other knee lesions not requiring surgery (refer to Specific Diagnosis); and/or non-displaced stable lesions. Acute injuries may require immobilization followed by active therapy with or without passive therapy.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. They should include range-of-motion (ROM), active therapies, and a home exercise program. Active therapies include, proprioception training, restoring normal joint mechanics, and clearing dysfunctions from distal and proximal structures. Passive as well as active therapies may be used for control of pain and swelling. Therapy should progress to strengthening and an independent home exercise program targeted to further improve ROM, strength, and normal joint mechanics influenced by structures distal and proximal to the knee. Refer to Therapeutic Procedures, Non-operative.

(i). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found in Therapeutic Procedures, Non-operative.

(e). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(f). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations: Surgery for isolated chondral defects may be indicated when functional deficits interfere with activities of daily living and/or job duties after 6 to 12 weeks of active patient participation in non-operative therapy. Identification of the lesion should have been accomplished by diagnostic testing procedures which describe the size of the lesion and stability of the joint. If a lesion is detached or has fluid underlying the bone on MRI, surgery may be necessary before a trial of conservative therapy is completed. Early surgery may consist of fixation or microfracture.

(a). Microfractures: Normally the first line of surgical treatment.

(i). Indications: An isolated small full-thickness articular chondral defect with normal joint space, when the patient has not recovered functionally after active participation in therapy. Patients 45 or younger are likely to have better results.

(b). Osteochondral Autograft Transfer System (OATS)

(i). Indications: The knee must be stable with intact ligaments and menisci, normal joint space and a large full-thickness defect less than 3 square cm and 1 cm depth. They should be 45 or younger, with a BMI less than 35, and engaged in athletics and/or an equally physically demanding occupation. Surgery may be indicated when functional deficits interfere with activities of daily living and/or job duties after 6 to 12 weeks of active patient participation in non-operative therapy. This procedure may be appropriate in a small subset of patients.

(c). Autologous chondrocyte implantation (ACI): These procedures are technically difficult and require specific physician expertise. Cartilage transplantation requires the harvesting and growth of patients' cartilage cells in a highly specialized lab and incurs significant laboratory charges. There is some evidence that transplants and microfractures do not differ on long-term effects. There is some evidence that autologous chrondrocyte implantation is not better than microfracture five years after surgery in patients younger than 45 presenting with Grade III -IV lesions. This procedure is controversial but may be appropriate in a small subset of patients with physically rigorous employment or recreational activities. It requires prior authorization.

(i). Indications: The area of the lesion should be between 2 square cm and 10 square cm. The patient should have failed four or more months of active participation in therapy and a microfracture, abrasion, arthroplasty or drilling with sufficient healing time, which may be from four months to over one year. The knee must be stable with intact ligaments and meniscus, and normal joint space. Patients should be 45 or younger, with a BMI less than 35, and engaged in athletics and/or an equally physically demanding occupation.

(d). Contraindications: General contraindications for grafts and transplants are individuals with obesity, inflammatory or osteoarthritis with multiple chondral defects, associated ligamentous or meniscus pathology, or who are older than 55 years of age.

(e). Prior to either graft or implantation 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.

(f). 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.

vii. Operative Procedures: Arthroscopy with debridement or shaving of cartilage, microfracture, drilling, abrasion arthroplasty, mosiacplasty or osteochondral autograft (OATS), fixation of loose osteochondral fragments and autologous chondrocyte implantation (ACI).

(a). Radiofrequency treatment is not recommended.

viii. Post-Operative Treatment

(b). Treatment may include the following: restricted weight-bearing, bracing, active therapy with or without passive therapy. Full weight-bearing usually occurs by or before 8 weeks.

(c). Continuous passive motion may be used after chondral procedures.

(d). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon. Return to full-duty usually occurs by between four and six months.

(e). Collateral Ligament Pathology

(i). Description/Definition: Strain or tear of medial or lateral collateral ligaments which provide some stabilization for the knee.

(ii). Occupational Relationship: Typically a result of forced abduction and external rotation to an extended or slightly flexed knee.

(iii). Specific Physical Exam Findings: Swelling or ecchymosis over the collateral ligaments and increased laxity or pain with applied stress.

(iv). Diagnostic Testing Procedures: X-rays to rule out fracture. Imaging is more commonly ordered when internal derangement is suspected.

(v). Non-Operative Treatment Procedures

[a]. Initial Treatment: braces, ice, and protected weight-bearing.

[b]. Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions area in Medications and Medical Management.

[c]. Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

[d]. Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. They should include range-of-motion (ROM), active therapies, and a home exercise program. Active therapies include proprioception training, restoring normal joint mechanics, and clearing dysfunctions from distal and proximal structures. Bracing may be beneficial. Passive as well as active therapies may be used for control of pain and swelling. Therapy should progress to strengthening and an independent home exercise program targeted to further improve ROM, strength, and normal joint mechanics influenced by structures distal and proximal to the knee. Refer to Therapeutic Procedures, Non-operative.

[i]. Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found in Therapeutic Procedures, Non-operative.

[e]. Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

[f]. Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

ix. Surgical Indications/Considerations: Surgery is rarely necessary except when functional instability persists after active participation in non-operative treatment or indications for surgery exist due to other accompanying injuries.

(b). 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.

x. Operative Procedures: Surgical repair.

xi. Post-operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist and using procedures as outlined in Therapeutic Procedures, Non-Operative.

(b). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

f. Meniscus Injury

i. Description/Definition - a tear, disruption, or avulsion of medial or lateral meniscus tissue. Locking of the knee or clicking is frequently reported. Patients may describe a popping, tearing, or catching sensation followed by stiffness.

ii. Occupational Relationship - trauma to the menisci from rotational shearing, torsion, and/or impact injuries while in a flexed position.

iii. Specific Physical Exam Findings: Joint line tenderness, Positive McMurray's test locked joint, or occasionally, effusion. The presence of joint line tenderness has a sensitivity of 85 percent and a specificity of 31 percent. The Apley's compression test is also used.

iv. Diagnostic Testing Procedures. Radiographs including standing Posterior/Anterior (PA), lateral, tunnel, and skyline views. MRI is the definitive imaging test. MRI is sensitive and specific for meniscal tear. However, meniscal MRI is frequently abnormal in asymptomatic injuries. In one study of volunteers without a history of knee pain, swelling, locking, giving way, or any knee injury, 16 percent of the volunteers had MRI-evident meniscal tears; among volunteers older than 45, 36 percent had MRI-evident meniscal tears. Therefore, clinical correlation with history and physical exam findings specific for meniscus injury is critically important.

(a). Providers planning treatment should therefore consider the patient's complaints and presence of arthritis on MRI carefully, knowing that not all meniscus tears in the middle aged and older population are related to the patients' complaints of pain.

(b). MRI arthrograms are used to diagnose recurrent meniscal tears particularly after previous surgery.

v. Non-operative Treatment

(a). Initial Treatment: ice, bracing, and protected weight-bearing.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. They should include range-of-motion (ROM), active therapies, and a home exercise program. Active therapies include, proprioception training, restoring normal joint mechanics, and clearing dysfunctions from distal and proximal structures. Passive as well as active therapies may be used for control of pain and swelling. Therapy should progress to strengthening and an independent home exercise program targeted to further improve ROM, strength, and normal joint mechanics influenced by structures distal and proximal to the knee. Refer to Therapeutic Procedures, Non-operative.

(i). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found as adjunctive in Therapeutic Procedures, Non-Operative.

(e). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(f). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations: Locked or blocked knee precluding active therapy; Isolated acute meniscus tear with appropriate physical exam findings; Meniscus pathology combined with osteoarthritis in a patient with functional deficits interfering with activities of daily living and/or job duties after 6 to 12 weeks of active patient participation in non-operative therapy.

(a). It is not clear that partial meniscectomy for a chronic degenerative meniscal tear is beneficial. Middle aged patients may do as well without arthroscopy and with therapy.

(b). Meniscal allograft should only be performed on patients between 20 and 45 with an otherwise stable knee, previous meniscectomy with 2/3 removed, lack of function despite active therapy, BMI less than 35, and sufficient joint surface to support repair.

(c). Medial collagen meniscus implants are considered experimental and not generally recommended. No studies have been done to compare this procedure to medial meniscus repair. There is some evidence to support the fact that collagen meniscal implant may slightly improve function and decrease risk of reoperation in patients with previous medial meniscal surgery. It remains unclear as to the extent that the procedure may decrease future degenerative disease. The procedure can only be considered for individuals with previous medial meniscal surgery and intact meniscus rim; without lateral meniscus lesions or Grade 4 Outerbridge lesions; and who need to return to heavy physical labor employment or demanding recreational activities. A second concurring opinion from an orthopedic surgeon specializing in knee surgery and prior authorization is required. Full weight-bearing is not allowed for 6 weeks and most patients return to normal daily activity after three months.

(e). 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.

vii. Operative Treatment: Repair of meniscus, partial or complete excision of meniscus or meniscus allograft or implant. Debridement of the meniscus is not recommended in patients with severe arthritis as it is unlikely to alleviate symptoms. Complete excision of meniscus should only be performed when clearly indicated due to the long-term risk of arthritis in these patients. Partial meniscectomy or meniscus repair is preferred to total meniscectomy due to easier recovery, less instability, and short-term functional gains.

viii. Post-operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist using the treatments found in Therapeutic Procedures, Non-operative.

(b). Treatment may include the following: Passive therapy progressively moving toward active therapy, bracing, cryotherapy and other treatments found in Therapeutic procedures Non-Operative.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

g. Patellar Fracture

i. Description/Definition: Fracture of the patella.

ii. Occupational Relationship: Usually from a traumatic injury such as a fall or direct blow

iii. Specific Physical Exam Findings: Significant hemarthrosis/effusion usually present. Extension may be limited and may indicate disruption of the extensor mechanism. It is essential to rule out open fractures; therefore a thorough search for lacerations is important.

iv. Diagnostic Testing Procedures. Aspiration of the joint and injection of local anesthetic may aid the diagnosis. A saline load injected in the joint can also help rule out an open joint injury. Radiographs may be performed, including tangential (sunrise) or axial views and x-ray of the opposite knee in many cases. CT or MRI is rarely needed.

v. Non-Operative Treatment Procedures

(a). Initial Treatment: For non-displaced closed fractures, protected weight-bearing and splinting for four to six weeks. Hinged knee braces can be used. When radiographs demonstrate consolidation, active motion and strengthening exercise may begin.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). Refer to comments related to osteoporosis in Therapeutic Procedures, Non-operative, Osteoporosis Management.

(e). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.

(f). Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions, after boney union has been achieved. They should include bracing then range-of-motion (ROM), active therapies including proprioception training, restoring normal joint mechanics, and clearing dysfunctions from adjacent structures, and a home exercise program. 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, restoring normal joint mechanics, influenced by proximal and distal structures. Therapy should include training on the use of adaptive equipment and home and work site evaluations when appropriate. Bracing may be appropriate. Refer to Therapeutic Procedures, Non-operative.

(i). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found as adjunctive in Therapeutic Procedures, Non-operative.

(g). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(h). Other therapies in Therapeutic Procedures. Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations: Open fractures require immediate intervention and may need repeat debridement. Internal fixation is usually required for comminuted or displaced fractures. Non-union may also require surgery.

vii. Operative Procedures: internal fixation; partial patellectomy or total patellectomy. Total patellectomy results in instability with running or stairs and significant loss of extensor strength. Therefore, this is usually a salvage procedure.

viii. Post-Operative Treatment

(b). Treatment may include protected weight-bearing and active therapy with or without passive therapy for early range of motion if joint involvement.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

(d). Hardware removal may be necessary after three to six months.

h. Patellar Subluxation:

i. Description/Definition: Incomplete subluxation or dislocation of the patella. Recurrent episodes can lead to subluxation syndrome that can cause frank dislocation of the patella. Patient may report a buckling sensation, pain with extension, or a locking of the knee with exertion.

ii. Occupational Relationship: Primarily associated with a direct contact lateral force. Secondary causes associated with shearing forces on the patella.

iii. Specific Physical Exam Findings: Lateral retinacular tightness with associated medial retinacular weakness, swelling, effusion, and marked pain with patellofemoral tracking/compression and glides. In addition, other findings may include atrophy of muscles, positive patellar apprehension test, and patella alta.

iv. Diagnostic Testing Procedures: CT or Radiographs including Merchant views, Q-angle, and MRI for loose bodies.

v. Non-Operative Treatment Procedures

(a). Initial Treatment: Reduction if necessary, ice, taping, and bracing followed by active therapy.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. They should include range-of-motion (ROM), active therapies, and a home exercise program. Active therapies include, proprioception training, restoring normal joint mechanics, and clearing dysfunctions from distal and proximal structures. Taping the patella or bracing may be beneficial. Passive as well as active therapies can be used for control of pain and swelling. Therapy should progress to strengthening and an independent home exercise program targeted to further improve ROM, strength, and normal joint mechanics influenced by structures distal and proximal to the knee. Specific strengthening should be done to optimize patellofemoral mechanics and address distal foot mechanics that influence the patellofemoral joint. Refer to Therapeutic Procedures, Non-operative.

(i). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found in Therapeutic Procedures, Non-operative.

(e). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(f). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations

(a). Fracture, loose bodies, and recurrent dislocation. Surgical repair of first-time dislocation in young adults generally is not recommended. Retinacular release, quadriceps reefing, and patellar tendon transfer should only be considered for subluxation after four to six months of active patient participation in non-operative treatment.

(c). 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.

vii. Operative Procedures: arthroscopy with possible arthrotomy; debridement of soft tissue and articular cartilage disruption; open reduction internal fixation with fracture; retinacular release, quadriceps reefing, and patellar tendon or lateral release with or without medial soft-tissue realignment.

viii. Post-operative Treatment

(a). Individualized rehabilitation program based upon communication between the surgeon and the therapist using the treatments found in Therapeutic Procedures, Non-operative.

(b). Treatment may include active therapy with or without passive therapy, bracing.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

i. Patellofemoral Pain Syndrome (aka Retropatellar Pain Syndrome)

i. Description/Definition. Patellofemoral pathologies are associated with resultant weakening, instability, and pain of the patellofemoral mechanism. Diagnoses can include patellofemoral chondromalacia, malalignment, persistent quadriceps tendonitis, distal patellar tendonitis, patellofemoral arthrosis, and symptomatic plica syndrome. Patient complains of pain, instability and tenderness that interfere with daily living and work functions such as sitting with bent knees, climbing stairs, squatting, running or cycling.

ii. Occupational Relationship: Usually associated with contusion; repetitive patellar compressive forces; shearing articular injuries associated with subluxation or dislocation of patella, fractures, and/or infection.

iii. Specific Physical Exam Findings: Findings on physical exam may include retinacular tenderness, pain with patellar compressive ranging, positive patellar glide test, atrophy of quadriceps muscles, positive patellar apprehensive test. Associated anatomical findings may include increased Q angle; ligament laxity, and effusion. Some studies suggest that the patellar tilt test (assessing the patella for medial tilt) and looking for active instability with the patient supine and knee flexed to 15 degrees and an isometric quad contraction, may be most useful for distinguishing normal from abnormal. Most patellar tests are more specific than sensitive.

iv. Diagnostic Testing Procedures: Radiographs including tunnel view, axial view of patella at 30 degrees, lateral view and Merchant views. MRI rarely identifies pathology. Occasional CT or bone scans.

v. Non-Operative Treatment Procedures

(a). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(b). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(c). Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. The program should include bracing and/or patellar taping, prone quad stretches, hip external rotation, balanced strengthening, range-of-motion (ROM), active therapies and a home exercise program. Active therapies include proprioception training, restoring normal joint mechanics, and clearing dysfunctions from distal and proximal structures. Passive as well as active therapies may be used for control of pain and swelling. Active therapeutic exercise appears to decrease pain; however, the expected functional benefits are unclear. Therapy should progress to strengthening and an independent home exercise program targeted to further improve ROM strength, and normal joint mechanics influenced by structures distal and proximal to the knee. Refer to Therapeutic Procedures, Non-operative.

(i). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found as adjunctive in Section F., Therapeutic Procedures, Non-operative. Orthotics may be useful in some cases.

(d). Knee pain, when associated with abnormal foot mechanics, may be favorably treated with appropriate orthotics.

(i). There is some evidence that pre-fabricated commercially available foot orthotic devices are more beneficial for patients with patellofemoral pain syndrome than flat shoe inserts. They may produce mild side effects such as rubbing or blistering which can be reduced with additional empirical measures such as heat molding or addition, and removal of wedges and inserts until patient comfort is achieved. In some cases, custom semi-rigid or rigid orthotics is necessary to decrease pronation or ensure a proper fit. There is no evidence regarding which orthotic design might be useful.

(e). Botulinum toxin injections for the relief of patellofemoral pain are considered experimental and are not recommended.

(f). Steroid Injections

(i). Steroid injections may decrease inflammation and allow the therapist to progress with functional exercise and ROM. 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 near the patellar tendon should generally be avoided. Injections should be minimized for patients less than 30 years of age.

[a]. Time to Produce Effect: One injection.

[b]. Maximum Duration: Three injections in one year spaced at least four to eight weeks apart.

(ii). Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for two weeks after injections.

(g). Extracorporeal Shock Wave Therapy (ESWT): There is no good research to support ESWT and therefore, it is not recommended.

(h). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(i). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations: patellar tendon disruption, quadriceps tendon rupture/avulsion, fracture. There is no evidence that surgery is better than eccentric training for patellar tendonopathy of the inferior pole (jumper's knee).

(a). Retinacular release, quadriceps reefing, and tibial transfer procedures should only be considered after four to six months of active patient participation in non-operative treatment in young active patients. There is no evidence that arthroscopy for patellofemoral syndrome is more efficacious than exercise.

(b). Lateral release and reconstruction is not recommended for patellofemoral arthritis or middle aged adults.

(c). In cases of severe Grade III-IV isolated patellofemoral arthritis where walking, steps, and other functional activities are significantly impacted after adequate conservative treatment, prosthesis may be considered in those less than 55 years. A patellofemoral arthroplasty is generally contraindicated if there is patellofemoral instability or malalignment, tibiofemoral mechanical malalignment, fixed loss of knee motion (greater than 10 degrees extension or less than 110 degrees flexion), inflammatory arthritis, and other systemic related issues. For patellar resurfacing, refer to Knee Arthroplasty.

(e). 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.

vii Operative Procedures: Arthroscopic debridement of articular surface, plica, synovial tissue, loose bodies; arthrotomy; open reduction internal fixation with fracture; patellar prosthesis with isolated Grade III-IV OA, and possible patellectomy for young active patients with isolated arthritis.

viii. Post-Operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist and using therapies as outlined in Therapeutic Procedures, Non-operative.

(b). Treatment may include active therapy with or without passive therapy; and bracing.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

j. Posterior Cruciate Ligament (PCL) Injury

i. Description/Definition: Rupture of PCL. May be associated with concurrent ACL rupture or collateral ligament injury.

ii. Occupational Relationship. Most often caused by a posterior force directed to flexed knee.

iii. Specific Physical Exam Findings: Findings on physical exam include acute effusion, instability, reverse Lachman's test, reverse pivot shift, posterior drawer test.

iv. Diagnostic Testing Procedures: MRI, radiographs including kneeling view, may reveal avulsed bone.

v. Non-operative Treatment Procedures:

(a). Initial Treatment: Ice, bracing, and protected weight-bearing followed by active therapy.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. They should include bracing then range-of-motion (ROM), active therapies, and a home exercise program. Active therapies include proprioception training, restoring normal joint mechanics, and clearing dysfunctions from distal and proximal structures. Passive as well as active therapies may be used for control of pain and swelling. Therapy should progress to strengthening and an independent home exercise program targeted to further improve ROM, strength, and normal joint structures distal and proximal to the knee. Refer to Therapeutic Procedures, Non-operative.

(i). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found in Therapeutic Procedures, Non-operative.

(e). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(f). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations:

(a). Carefully consider the patients' normal daily activity level before initiation of surgical intervention. Isolated Grade 1 instability does not require surgical intervention. Grades 2 or 3 may have surgical intervention if there remains demonstrable instability which interferes with athletic or work pursuits of the patient. In a second degree strain there is significant posterior motion of the tibia on the femur in active testing. A third degree strain demonstrates rotary instability due to medial or lateral structural damage. Surgery is most commonly done when the PCL rupture is accompanied by multi-ligament injury. Not recommended as an isolated procedure in patients over 50 with Grade 3 or 4 osteoarthritis.

(c). 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.

vi. Operative Procedures: Autograft or allograft reconstruction.

vii. Post-Operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist and using therapies as outlined in Section F. Therapeutic Procedures, Non-operative.

(b). Treatment may include active therapy with or without passive therapy, bracing.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

k. Tendonopathy

i. Description/Definition. Inflammation of the lining of the tendon sheath or of the enclosed tendon. Usually occurs at the point of insertion into bone or a point of muscular origin. Can be associated with bursitis, calcium deposits, or systemic connective diseases.

ii. Occupational Relationship: Extreme or repetitive trauma, strain, or excessive unaccustomed exercise or work.

iii. Specific Physical Exam Findings: Involved tendons may be visibly swollen with possible fluid accumulation and inflammation; popping or crepitus; and decreased ROM.

iv. Diagnostic Testing Procedures. Lab work may be done to rule out inflammatory disease. Other tests are rarely indicated.

v. Non-Operative Treatment Procedures

(a). Initial Treatment: Ice, protected weight-bearing and/or restricted activity, possible taping and/or bracing.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. They should include range-of-motion (ROM), active therapies, including a home exercise program. Active therapies include, proprioception training, restoring normal joint mechanics, and clearing dysfunctions from distal and proximal structures. Passive as well as active therapies may be used for control of pain and swelling. Therapy should progress to strengthening and an independent home exercise program targeted to further improve ROM, strength, and normal joint mechanics influenced by structures distal and proximal to the knee. Refer to Therapeutic Procedures, Non-operative.

(i). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found as adjunctive in Therapeutic Procedures, Non-operative.

(e). For isolated patellar tendonopathy, patellar tendon strapping or taping may be appropriate.

(f). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(g). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

(h). Therapeutic Injections: Steroid injections may decrease inflammation and allow the therapist to progress with functional exercise and ROM. 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 less than 30 years of age.

(i). Time to Produce Effect: One injection.

(ii). Maximum Duration: Three injections in one year spaced at least four to eight weeks apart.

(iii). Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for two weeks after injections.

vi. Surgical Indications/Considerations:

(a). Suspected avulsion fracture, or severe functional impairment unresponsive to a minimum of four months of active patient participation in non-operative treatment.

(c). 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.

vii. Operative Procedures: Tendon repair. Rarely indicated and only after extensive conservative therapy.

viii. Post-Operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist and using therapies as outlined in Therapeutic Procedures, Non-Operative.

(b). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

3. Hip and Leg

a. Acetabular Fracture

i. Description/Definition: Subgroup of pelvic fractures with involvement of the hip articulation.

ii. Occupational Relationship: Usually from a traumatic injury such as a fall or crush.

iii. Specific Physical Exam Findings: Displaced fractures may have short and/or abnormally rotated lower extremity.

iv. Diagnostic Testing Procedures: Radiographs, CT scanning.

v. Non-Operative Treatment Procedures

(a). Initial Treatment: Although surgery is frequently required, protected weight-bearing may be considered for un-displaced fractures or minimally displaced fractures that do not involve the weight-bearing surface of the acetabular dome.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). Refer to comments on osteoporosis in Ankle Sprain/Fracture.

(e). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.

(f). Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions, after boney union has been achieved. They should include bracing then range-of-motion (ROM), active therapies, and a home exercise program. Active therapies include ambulation with appropriate assistive device, 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 proximal and distal structures. Therapy should include training on the use of adaptive equipment and home and work site evaluations when appropriate. Bracing may be appropriate. Refer to Therapeutic Procedures, Non-Operative.

(i). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found as adjunctive in Therapeutic Procedures, Non-operative.

(g). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(h). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations. Displaced or unstable fracture.

vii. Operative Procedures: Usually open reduction and internal fixation or total hip replacement.

viii. Post-Operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist, and using therapies as outlined in Therapeutic Procedures, Non-operative. In all cases, communication between the physician and therapist is important to the timing of weight-bearing, and exercise progressions.

(b). Treatment usually includes active therapy with or without passive therapy for early range of motion and weight-bearing then progression to, strengthening, flexibility, neuromuscular training, and gait training with appropriate assistive devices.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

b. Aggravated Osteoarthritis

i. Description/Definition: hip pain with radiographic evidence of joint space narrowing or femoral acetabular osteophytes, and sedimentation rate less than 20mm/hr with symptoms. Patients usually have gradual onset of pain increasing with use and relieved with rest, progressing to morning stiffness and then to night pain.

ii. Occupational Relationship: The provider must establish the occupational relationship by establishing a change in the patient's baseline condition and a relationship to work activities including but not limited to repetitive heavy lifting or specific injury to the hip.

(a). Other causative factors to consider: Prior significant injury to the hip may predispose the joint to osteoarthritis. In order to entertain previous trauma as a cause, the patient should have a medically documented injury with radiographs or MRI showing the level of anatomic change. The prior injury should have been at least two years from the presentation for the new complaints and there should be a significant increase of pathology on the affected side in comparison to the original imaging or operative reports and/or the opposite un-injured side or extremity.

iii. Specific Physical Exam Findings: Bilateral exam including knees and low back is necessary to rule out other diagnoses. Pain with the hip in external and/or internal hip rotation with the knee in extension is the strongest indicator.

iv. Diagnostic Testing Procedures: standing pelvic radiographs demonstrating joint space narrowing to 2 mm or less, osteophytes or sclerosis at the joint. MRI may be ordered to rule out other more serious disease.

v. Non-Operative Treatment Procedures

(a). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). 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 gait training with appropriate assistive devices, 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 proximal and distal structures. Therapy should include training on the use of adaptive equipment and home and work site evaluations when appropriate Refer to Therapeutic Procedures, Non-operative. There is good evidence that a supervised therapeutic exercise program with an element of strengthening is an effective treatment for hip osteoarthritis.

(i). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found as adjunctive in Therapeutic Procedures, Non-operative. There is some evidence that manual therapy, including stretching and traction manipulation by a trained provider, produces functional improvement in hip osteoarthritis and may be a suitable treatment option.

[a]. Aquatic therapy may be used as a type of active intervention to improve muscle strength and range of motion when land-based therapy is not well-tolerated.

[b]. The use of insoles, adaptive equipment, cane, may be beneficial.

[c]. There is some evidence that acupuncture may produce improvement in hip pain and function, making it a suitable treatment option for patients. Refer to Therapeutic Procedures, Non-operative.

[d]. Steroid Injections - Steroid injections may decrease inflammation and allow the therapist to progress with functional exercise and ROM.

[i]. Time to Produce Effect: One injection.

[ii]. Maximum Duration: Three injections in one year spaced at least four to eight weeks apart.

[iii]. Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for two weeks after injections.

[e]. Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

[f]. Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations

(a). When pain interferes with ADLs and the patient meets the following: low surgical risk, adequate bone quality, and failure of previous non-surgical interventions including weight control, therapy with active patient participation, and medication. Refer to Therapeutic Procedures-operative, Hip Arthroplasty, for indications specific to the procedure.

(d). 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.

vii. Operative Procedures: Prosthetic replacement (traditional or minimally invasive), or resurfacing.

viii. Post-Operative Treatment

(a). In all cases, communication between the physician and therapist is important to the timing of weight-bearing and exercise progressions.

(b). For prosthetic replacement, refer to Hip Arthroplasty.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

c. Femoral Osteonecrosis (Avascular Necrosis (AVN) of the Femoral Head)

i. Description/Definition. Death of the bone tissue of the femoral head following loss of blood supply to the area. Destruction of the articular surfaces of the hip joint may lead to arthritis.

ii. Occupational Relationship. Trauma resulting in displaced subcapital fracture of the hip or hip dislocation may cause AVN. Previous surgical procedures and systemic steroids may lead to AVN. In the general population risk factors include, but are not limited to alcohol abuse, smoking, Caisson disease (also known as the bends), sickle cell anemia, autoimmune disease, and hypercoagulable states. Often, the cause cannot be identified. Involvement of the opposite hip may occur in more than half of cases not caused by trauma.

iii. Specific Physical Exam Findings. Hip or groin pain made worse by motion or weight-bearing and alleviated by rest is the classical presentation. Symptoms may begin gradually, often months after the vascular compromise of blood flow. A limp may result from the limited toleration of weight-bearing.

iv. Diagnostic Testing Procedures. X-ray abnormalities include sclerotic changes, cystic lesions, joint space narrowing, and degeneration of the acetabulum. The x-ray may be normal in the first several months of the disease process. AVN should be suspected when hip pain occurs and risk factors are present. X-rays should be done first, but may be followed by an MRI. When AVN is not due to trauma, both hips should be imaged.

v. Non-operative Treatment Procedures

(a). Initial Treatment: protected weight-bearing and bracing followed by active therapy with or without passive therapy. Conservative approaches may suffice when the lesion is small, but larger lesions are expected to require surgical intervention when symptoms are disabling.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management. Weight-bearing restrictions may be appropriate.

(d). Smoking may affect bone healing. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.

(e). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(f). Other therapies in Therapeutic Procedures, Non-operative, may be employed in individual cases.

vi. Surgical Indications/Considerations: Core decompression may appropriate for some patients with early disease (Stages 1 and 2A) who have functionally disabling symptoms. Femoral head osteotomies or resurfacing hemiarthroplasties may also be appropriate for younger patients when disease is limited to the femoral head. Those 50 or older and patients with total joint collapse or severely limiting disease will usually require an implant arthroplasty.

(b). 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.

vii. Operative Procedures. Osteotomy, core decompression with or without bone graft, prosthetic replacement. Refer to Therapeutic Procedures-operative for details.

viii. Post-operative Treatment

(a). Anticoagulant therapy to prevent deep venous thrombosis for most procedures. Refer to Therapeutic Procedures, Non-operative.

(b). Treatment usually includes active therapy with or without passive therapy. Refer to Therapeutic Procedures-Operative and specific procedures for further details.

(c). An individualized rehabilitation program based upon communication between the surgeon and the therapist using the treatments found in Therapeutic Procedures, Non-operative.

(d). Treatment should include gait training with appropriate assistive devices.

(e). Therapy should include training on the use of adaptive equipment and home and work site evaluation when appropriate.

(f). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon

d. Femur Fracture

i. Description/Definition. Fracture of the femur distal to the lesser trochanter.

ii. Occupational Relationship. Usually from a traumatic injury such as a fall or crush.

iii. Specific Physical Exam Findings: May have a short, abnormally rotated extremity. Effusion if the knee joint is involved.

iv. Diagnostic Testing Procedures: Radiographs. Occasionally CT scan or MRI particularly if the knee joint is involved.

v. Non-operative Treatment Procedures

(a). Initial Treatment. Although surgery is usually required, non-operative procedures may be considered in stable, non-displaced fractures and will require protected weight-bearing.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Back pain may occur after femur fracture and should be addressed and treated as necessary.

(d). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, weight management. Weight-bearing restrictions may be appropriate.

(e). Refer to comments related to osteoporosis in Therapeutic Procedures, Non-operative, Osteoporosis Management.

(f). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.

(g). Orthotics such as heel lifts and custom shoe build-ups may be required when leg-length discrepancy persists.

(h). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(i). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations. Femoral neck fracture or supracondylar femur fracture with joint incongruity.

vii. Operative Procedures: Rod placement or open internal fixation.

viii. Post-Operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist, using therapies as outlined in Therapeutic Procedures, Non-operative. In all cases, communication between the physician and the therapist is important to the timing of weight-bearing and exercise progression.

(b). Treatment usually includes active therapy with or without passive therapy for protected weight-bearing, early range of motion if joint involvement.

(c). Refer to bone-growth stimulators in Therapeutic Procedures, Non-operative.

(d). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

(e). Hamstring Tendon Rupture

(i). Description/Definition. Most commonly, a disruption of the muscular portion of the hamstring. Extent of the tear is variable. Occasionally a proximal tear or avulsion. Rarely a distal injury.

(ii). Occupational Relationship: Excessive tension on the hamstring either from an injury or from a rapid, forceful contraction of the muscle.

(iii). Specific Physical Exam Findings: Local tenderness, swelling, ecchymosis.

(iv). Diagnostic Testing Procedures: Occasionally radiographs or MRI for proximal tears/possible avulsion.

(v). Non-operative Treatment Procedures

[a]. Initial Treatment: Protected weight-bearing and ice.

[b]. Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

[c]. Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, and weight management.

[d]. Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. They may 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 proximal and distal structures. Bracing may be appropriate. Refer to Therapeutic Procedures, Non-operative.

[i]. Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found as adjunctive in Therapeutic Procedures, Non-operative.

[e]. Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

[f]. Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations

(a). Surgery is indicated for proximal or distal injuries only when significant functional impairment is expected without repair. If surgery is indicated, it is preferably performed within three months.

(c). 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.

vii. Operative Procedures: Re-attachment of proximal avulsions and repair of distal tendon disruption.

viii. Post-Operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist using therapies as outlined in Therapeutic Procedures, Non-operative. In all cases, communication between the physician and therapist is important to the timing of weight-bearing and exercise progressions.

(b). Treatment may include protected weight-bearing and active therapy with or without passive therapy. Splinting in a functional brace may reduce time off work.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

f. Hip Dislocation

i. Description/Definition. Disengagement of the femoral head from the acetabulum.

ii. Occupational Relationship. Usually from a traumatic injury such as a fall or crush.

iii. Specific Physical Exam Findings: Most commonly a short, internally rotated, adducted lower extremity with a posterior dislocation and a short externally rotated extremity with an anterior dislocation.

iv. Diagnostic Testing Procedures: Radiographs, CT scanning.

v. Non-operative Treatment Procedures

(a). Initial Treatment: Urgent closed reduction with sedation or general anesthesia.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions. They should include bracing then range-of-motion (ROM), active therapies, and a home exercise program. Active therapies include proprioception training, gait training with appropriate assistive devices, 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 proximal and distal structures. Therapy should include training on the use of adaptive equipment and home and work site evaluations when appropriate. Bracing may be appropriate Refer to Therapeutic Procedures, Non-operative.

(i). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found as adjunctive in Therapeutic Procedures, Non-operative.

(e). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(f). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations: Failure of closed reduction. Associated fracture of the acetabulum or femoral head, loose fragments in joint or open fracture.

(a). Because smokers have a higher risk of non-union and post-operative costs, when a fracture is involved 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.

vii. Operative Procedures. Open reduction of the femoral head or acetabulum and possible internal fixation.

viii. Post-operative Treatment Procedures

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist using therapies as outlined in Therapeutic Procedures, Non-operative. In all cases, communication between the physician and therapist is important to the timing of weight-bearing and exercise progressions.

(b). Treatment should include gait training with appropriate assistive devices.

(c). Treatment may include protected weight-bearing and active therapy with or without passive therapy for early range of motion.

(d). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

g. Hip Fracture

i. Description/Definition. Fractures of the neck and peri-trochanteric regions of the proximal femur.

ii. Occupational Relationship: Usually from a traumatic injury such as a fall or crush. Patients with intracapsular femoral fractures have a risk of developing avascular necrosis of the femoral head requiring treatment months to years after the initial injury.

iii. Specific Physical Exam Findings. Often a short and externally rotated lower extremity.

iv. Diagnostic Testing Procedures: Radiographs. Occasional use of CT scan or MRI.

v. Non-operative Treatment Procedures

(a). Initial Treatment: protected weight-bearing and bracing followed by active therapy with or without passive therapy. Although surgery is usually required, non-operative procedures may be considered in stable, non-displaced fractures.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Back pain may occur after hip fracture and should be addressed and treated as necessary.

(d). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management. Weight-bearing restrictions may be appropriate.

(e). Refer to comments on osteoporosis in Ankle Sprain/Fracture.

(f). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.

(g). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(h). Other therapies in Therapeutic Procedures, Non-operative, may be employed in individual cases.

vi. Surgical Indications/Considerations. Surgery is indicated for unstable peritrochanteric fractures and femoral neck fractures.

vii. Operative Procedures: Prosthetic replacement for displaced femoral neck fractures. Reduction and internal fixation for peritrochanteric fractures, and un-displaced, or minimally-displaced neck fractures.

viii. Post-operative Treatment

(a). Anti coagulant therapy to prevent deep venous thrombosis. Refer to Therapeutic Procedures, Non-operative.

(b). Treatment usually includes active therapy with or without passive therapy.

(c). An individualized rehabilitation program based upon communication between the surgeon and the therapist using the treatments found in Therapeutic Procedures, Non-operative.

(d). Treatment should include gait training with appropriate assistive devices.

(e). Therapy should include training on the use of adaptive equipment and home and work site evaluation when appropriate.

(f). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

h. Impingement/Labral Tears

i. Description/Definition: Two types of impingement are described pincer; resulting from over coverage of the acetabulum and/or cam; resulting from aspherical portion of the head and neck junction. Persistence of these abnormalities can cause early arthritis or labral tears. Labral tears can also be isolated; however, they are frequently accompanied by bony abnormalities. Patients usually complain of catching or painful clicking which should be distinguished from a snapping iliopsoas tibial tendon. A pinch while sitting may be reported and hip or groin pain.

ii. Occupational Relationship: Impingement abnormalities are usually congenital; however, they may be aggravated by repetitive rotational force or trauma. Labral tears may accompany impingement or result from high energy trauma.

iii. Specific Physical Exam Findings. Positive labral tests.

iv. Diagnostic Testing Procedures. Cross table laterals, standing AP pelvis and frog leg lateral x-rays. MRI may reveal abnormality; however, false positives and false negatives are also possible. MRI arthrogram with gadolinium should be performed to diagnose labral tears, not a pelvic MRI. Intra-articular injection should help rule out extra-articular pain generators. To confirm the diagnosis, the patient should demonstrate changes on a pain scale accompanied by recorded functional improvement post-injection. This is important, as labral tears do not always cause pain and over-diagnosis is possible using imaging alone.

v. Non-Operative Treatment Procedures

(a). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(b). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, reducing hip adduction and internal rotation home exercise, joint protection, and weight management.

(c). 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 proximal and distal structures. Refer to Therapeutic Procedures, Non-operative.

(i). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found as adjunctive in Therapeutic Procedures, Non-operative.

(d). Steroid Injections. Steroid injections may decrease inflammation and allow the therapist to progress with functional exercise and ROM.

(i). Time to Produce Effect: One injection.

(ii). Maximum Duration: Three injections in one year spaced at least four to eight weeks apart.

(iii). Steroid injections should be used cautiously in diabetic patients. Diabetic patients should be reminded to check their blood glucose levels at least daily for two weeks after injections.

(e). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(f). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations:

(a). Surgery is indicated when functional limitations persist after eight weeks of active patient participation in treatment, there are clinical signs and symptoms suggestive of the diagnosis and other diagnoses have been ruled out.

(d). 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.

vii. Operative Procedures: Debridement or repair of labrum and removal of excessive bone.

viii. Post-operative Treatment

(a). When bone is removed and/or the labrum is repaired, weight-bearing restrictions usually apply.

(b). An individualized rehabilitation program based upon communication between the surgeon and the therapist that should include gait training with appropriate assistive devices. Refer to Therapeutic Procedures Non-operative.

(c). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

i. Pelvic Fracture

i. Description/Definition. Fracture of one or more components of the pelvic ring (sacrum and iliac wings).

ii. Occupational Relationship. Usually from a traumatic injury such as a fall or crush.

iii. Specific Physical Exam Findings. Displaced fractures may cause pelvic deformity and shortening, or rotation of the lower extremities.

iv. Diagnostic Testing Procedures: Radiographs, CT scanning. Occasionally MRI, angiogram, urethrogram, emergent sonogram.

v. Non-operative Treatment Procedures

(a). Initial Treatment: Protected weight-bearing. Although surgery is usually required, non-operative procedures may be considered in a stable, non-displaced fracture.

(b). Medications such as analgesics and anti-inflammatories may be helpful. Refer to medication discussions in Medications and Medical Management.

(c). Patient education should include instruction in self-management techniques, ergonomics, body mechanics, home exercise, joint protection, and weight management.

(d). Refer to comments related to osteoporosis in Therapeutic Procedures, Non-operative, Osteoporosis Management.

(e). Smoking may affect fracture healing. Patients should be strongly encouraged to stop smoking and be provided with appropriate counseling by the physician.

(f). Benefits may be achieved through therapeutic rehabilitation and rehabilitation interventions, after boney union has been achieved. They should include bracing then range-of-motion (ROM), active therapies, and a home exercise program. Active therapies include, proprioception training, gait training with appropriate assistive devices, 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 proximal and distal structures. Therapy should include training on the use of adaptive equipment and home and work site evaluations when appropriate. Refer to Therapeutic Procedures, Non-operative.

(i). Passive modalities are most effective as adjunctive treatments to improve the results of active treatment. They may be used as found as adjunctive in Therapeutic Procedures, Non-operative.

(g). Return to work with appropriate restrictions should be considered early in the course of treatment. Refer to Return to Work.

(h). Other therapies in Therapeutic Procedures, Non-operative may be employed in individual cases.

vi. Surgical Indications/Considerations. Unstable fracture pattern, or open fracture.

vii. Operative Procedures. External or internal fixation dictated by fracture pattern.

viii. Post-Operative Treatment

(a). An individualized rehabilitation program based upon communication between the surgeon and the therapist using therapies as outlined in Therapeutic Procedures, Non-operative. In all cases, communication between the physician and therapist is important to the timing of weight-bearing and exercise progressions.

(b). Treatment usually includes active therapy with or without passive therapy for gait, pelvic stability, strengthening, and restoration of joint and extremity function. Treatment should include gait training with appropriate assistive devices.

(c). Graduated weight-bearing according to fracture healing.

(d). Return to work and restrictions after surgery may be made by an attending physician experienced in occupational medicine in consultation with the surgeon or by the surgeon.

j. Tendonopathy: Refer to Tendonopathy for general recommendations.

k. Tibial Fracture

i. Description/Definition. Fracture of the tibia proximal to the malleoli.

(a). Open tibial fractures are graded in severity according to the Gustilo-Anderson Classification:

(i). Type I: Less than 1 cm (puncture wounds).

(ii). Type II: 1 to 10 cm.

(iii). Type III-A: Greater than 10 cm, sufficient soft tissue preserved to cover the wound (includes gunshot wounds and any injury in a contaminated environment).

(iv). Type III-B: Greater than 10 cm, requiring a soft tissue coverage procedure.

(v). Type III-C: With vascular injury requiring repair.

ii. Occupational Relationship. Usually from a traumatic injury such as a fall or crush.

iii. Specific Physical Exam Findings. May have a short, abnormally rotated extremity. Effusion if the knee joint involved.

iv. Diagnostic Testing Procedures: Radiographs. CT scanning or MRI.

v. Non-operative Treatment Procedures:

(a). Initial Treatment - protected weight-bearing; functional bracing. There is some evidence for use of pneumatic braces with stress fractures.