Barriers Between Injury and Returnto-Work. Lower Extremity. Why the Extreme Variability

Transcription

1 Barriers Between Injury and Returnto-Work in the Lower Extremity Why the Extreme Variability

2 Barriers to Diagnosis Failure or delay in reporting injury Employee expectations: Not really a serious injury Apprehension that report could cause employment difficulties

3 Barriers to Diagnosis Inadequate work-up Referral to medical personnel insufficiently trained in orthopedic problems Confusing history/pre-existing conditions

4 Barriers to Treatment Wrong diagnosis Ignorance of differential diagnosis Delay in referral Bureaucracy Patient factors Transportation Noncompliance

5 Barriers to Treatment Differential diagnosis includes: Fractures in other locations Hindfoot Midfoot Lateral process talus Osteochondral lesions Other ligament injuries Syndesmosis Lisfranc

6 Barriers to Treatment Differential diagnosis (cont d) Tendon injuries Achilles Ant/post tibialis Infection Rheumatologic disorders

7 Barriers to Treatment Other injuries Upper extremity injuries -inability to use crutches Iatrogenic delays Other medical problems Anesthesia risk Circulatory/smoking Diabetes

8 Treatment Non-surgical Rest Activity modification Physical therapy Shoewear Orthoses

9 Treatment Operative Arthroscopic Open

10 Surgical treatment Arthroscopic Smaller incisions---shorter recovery times? Not all conditions treatable by arthroscopy

11 Surgical Treatment u Open procedures u Wider exposure u Generally longer recovery

12 Barriers to Recovery Patient Issues Previously discussed medical issues Home situation Hygiene Nutrition Compliance with post-op instructions Ice/elevation, rest exercises

13 Barriers to Recovery Availability of optimal rehabilitation Physical therapy Aquatic therapy Self-directed exercises Compliance Pain

14 Barriers to RTW Is light duty available? Sedentary? Ability to elevate extremity? Transportation Can patient drive? Shoewear issues Is there a shoewear requirement? Swelling?

15 Barriers to RTW Pain Should all pain be gone? How much pain is OK? Swelling When should the swelling be gone? Does swelling indicate a problem?

16 Case presentation History: inversion injury at work, previous ankle sprains without specific treatment rendered. Treatment: Placed in tibial walker for two weeks, sent to physical therapy for two weeks. Returned to work one month after injury with no restrictions in spite of complaints of continued pain.

17 Case presentation Referred to me by judge five months later after hiring attorney to contest the discontinuation of benefits. C/o continued pain, feeling of instability, swelling. Physical exam: Moderate edema, positive anterior drawer, tender over anterior joint line and lateral gutter.

18 Case presentation Physical exam- anterior drawer

19 Case presentation Xrays: Anterior tibial osteophyte

20 Case presentation MRI: Grade III sprain ATFL, articular cartilage injury

21 Case Presentation Arthroscopic debridement osteochondral lesion Lateral ligament reconstruction

22 Rehabilitation Preferably starts preoperatively Equally important as surgical procedure Compatible with early return to light duty

23 Rehabilitation-phase I Lateral ligament reconstruction, week 0-2 Cast immobilization, non-weight bearing Ice/elevation Calf isometrics, quad,hamstring, hip isometrics Toe ROM

24 Rehabilitation-phase I Lateral ligament reconstruction, week 3-4 Advance weight bearing to full in boot Active ROM ankle, limited arc Isometric inversion/eversion Proprioceptive training starts Scar mobilization Continue toe ROM, thigh/hip strengthening Modalities as needed for edema reduction, pain control Start (week 4) seated BAPS board

25 Rehabilitation-phase I Lateral ligament reconstruction, week 5-6 Continue ambulation in tibial walker Start weaning from boot to lace-up brace/shoe Start active inversion/eversion Stationary bicycle (out of boot) Start resistive dorsiflexion/plantarflexion Seated BAPS inversion/eversion

26 Rehabilitation-phase II Goals: Full ROM, all planes Near normal strength and endurance Normal gait pattern Lateral ligament reconstruction, week 7-12 Transition to lace up brace full time Begin treadmill Theraband exercises in all planes Initiate subtalar mobilization Continue proximal strengthening Start leg press (week7), toe raises (week 8), light jogging (week 10)

27 Rehabilitation-phase II Lateral ligament reconstruction, week Ambulation in shoe without brace (level ground) Eccentric exercises in all planes (manual resistance) Begin plyometrics week 12 Standing BAPS board Continue manual techniques Criteria fpr advancement to Phase III: -ability to ambulate without deviation -strength 4+/5 all planes -able to tolerate light jogging for 3 minutes without increase in symptoms

28 Rehabilitation-phase III Weeks Therapy goals: return to work-specific agility drills, normal strength

29 Rehabilitation-phase III Lateral ligament reconstruction, week 13+ Hop drills/ single leg hops,cutting drills,shuttle runs Continue quad/hamstring/hip/calf strengthening

30 Intermediate- and Long- term Issues Swelling Pain Plantar fasciitis Difficulties walking uphill (restricted dorsiflexion) Arthritis

31 Intermediate- and Long- term Issues Prognosis Arthritis Future needs Appliances Medications surgery Permanent Impairment?

32 Future What can be done to improve the system? Earlier referral to appropriate subspecialist Better patient education on the front end Prevention