Medical Foundations of Workers' Compensation Conditions of The

Medical Foundations of Workers’ Compensation Conditions of the Feet

Objective: This section will introduce the student to basic medical terms, familiarize them with common diagnoses, and review treatment options relating to conditions of the feet.

The Foot

Common Injuries Achilles Bursitis or Tendinitis Heel Spurs Forefoot (Sesamoid, Phalanges) Fracture Metatarsal Bone Fracture Midfoot (Cuboid, Cuneiform, Navicular) Fracture Plantar Fasciitis Sprains and Strains

Tests and Treatments Excision of Bone Spur Excision of Morton's Neuroma

1 Medical Foundations of Workers’ Compensation

Conditions of the Feet

The Foot The foot is a complex structure made up of 26 bones, 33 joints, 107 ligaments, and 19 muscles and tendons. All of them deserve focused attention and care.

Foot Skeletal Structure

2 The disarticulated bones of the left foot, from above. (The talus and calcaneus remain articulated) 1 Calcaneus 2 Talus 3 Navicular 4 Medial cuneiform 5 Intermediate cuneiform 6 Lateral cuneiform 7 Cuboid 8 First metatarsal 9 Second metatarsal 10 Third metatarsal 11 Fourth metatarsal 12 Fifth metatarsal 13 Proximal phalanx of great toe 14 Distal phalanx of great toe 15 Proximal phalanx of second toe 16 Middle phalanx of second toe 17 Distal phalanx of second toe

Bones of the tarsus, the back part of the foot Talus Calcaneus Navicular bone Cuboid bone Medial, intermediate and lateral cuneiform bones

Bones of the metatarsus, the forepart of the foot First to fifth metatarsal bones (numbered from the medial side)

Bones of the toes or digits Phalanges -- a proximal and a distal phalanx for the great toe; proximal, middle and distal phalanges for the second to fifth toes

Sesamoid bones Two always present in the tendons of flexor hallucis brevis

Origin and meaning of some terms associated with the foot: Tibia: Latin for a flute or pipe; the shin bone has a fanciful resemblance to this wind instrument.

Fibula: Latin for a pin or skewer; the long thin bone of the leg. Adjective fibular or peroneal, which is from the Greek for pin.

Tarsus: Greek for a wicker frame; the basic framework for the back of the foot.

3 Metatarsus: Greek for beyond the tarsus; the forepart of the foot.

Talus (astragalus): Latin (Greek) for one of a set of dice; viewed from above the main part of the talus has a rather square appearance.

Calcaneus: from the Greek for heel; the heel bone.

Navicular (scaphoid): Latin (Greek) for boat-shaped; the navicular bone roughly resembles a saucer-shaped coracle.

Cuboid: Greek for cube-shaped.

Cuneiform: Latin for wedge-shaped.

Phalanx: Greek for a row of soldiers; a row of bones in the toes. Plural phalanges.

Sesamoid: Greek for shaped like a sesame seed.

Digitus: Latin for finger or toe. Digiti and digitorum are the genitive singular and genitive plural -- of the toe(s).

Hallux: Latin for the great toe. Hallucis is the genitive singular -- of the great toe.

Dorsum: Latin for back; the upper surface of the foot. Adjective dorsal.

Plantar: adjective from planta, Latin for the sole of the foot.

Common Injuries Achilles Bursitis or Tendinitis Definition Achilles bursitis is a painful and inflammatory condition affecting either the tendon (tendinitis) that joins the heel bone to the calf muscle (Achilles tendon) or the small sacs (bursae) that surround that tendon. Tendons are fibrous tissues connecting muscles to bones or other structures. Bursae are small sacs or pouches found over most bony prominences. They provide cushioning and protect tendons and ligaments from wear by producing a lubricating synovial fluid that reduces the effects of friction and impact.

Risk The Achilles tendon serves to raise and lower the heel during movement such as walking, running, and jumping. Repetitive forces on this tendon and its bursae from these types of activities can cause either of these inflammatory conditions. Changes in the tendon due to aging may also make the tendon more prone to inflammation. Individuals at a higher risk for developing this condition include manual laborers and athletes who participate in running or jumping activities. Wearing ill-fitting shoes may also contribute to the development of tendinitis.

4 Those with a familial high cholesterol condition called familial hyperlipidemia type II have a higher risk of getting tendinitis. Some individuals with this type of cholesterol abnormality may develop fat-like deposits (xanthomas) in tendons that result in Achilles tendinitis.

Incidence and Prevalence The exact incidence and prevalence of Achilles bursitis or tendinitis is not reported, but this condition is common in active, middle-aged individuals.

Diagnosis History With either Achilles tendinitis or bursitis, individuals generally report heel or calf pain that is made worse by activity, although there may be pain while the individual is at rest. The area overlying the inflammation may be tender and swollen. Other reported signs include swelling around the joint and palpable grating (crepitus) when flexing and extending the foot. The individual may also report pain associated with occupational tasks and sports activities or a history of trauma to this area.

Physical Exam With tendinitis, physical examination usually reveals swelling and tenderness. Mobility (ankle extension, especially bending the foot up) may be limited because of pain. An examination of the individual's shoes may provide information with regard to the individual's gait or running pattern. Cases of Achilles bursitis usually involve swelling on both sides of the tendon, with the individual experiencing pain upon extension of the ankle.

Tests No diagnostic tests are usually required for Achilles tendinitis, although plain film x-rays of the joint and surrounding area may be taken. Diagnostic ultrasound may also be useful in examining the area, particularly if the tendon is viewed during contraction. When the physician is not sure if the tendon is intact, MRI may be performed to identify tears, partial tears, inflammation, or tumors. In cases of suspected Achilles bursitis, joint or synovial fluid may be removed through suction with a needle (aspiration) and examined microscopically. This fluid will be cultured to help the physician diagnose whether bursitis is from infection or inflammation.

Treatment The goal of treatment is to relieve pain, reduce inflammation, and rest the joint. Specific recommendations depend on the cause of the injury. Treatment may consist of a heel lift, application of ice, and protective pressure wraps to the area. The individuals should also decrease or modify the repetitive activity to allow the tendon to heal properly and prevent symptom recurrence. Nonsteroidal anti-inflammatory drugs (NSAIDs) are useful in relieving pain and inflammation. Severe cases of Achilles tendinitis may be treated by immobilizing the muscle and tendon using a brace, cane, or crutch and, in severe cases, by casting of the foot and ankle. Following a recovery period, the individual may receive physical therapy and instruction in stretching exercises.

In cases of Achilles bursitis, the joint should be elevated and gentle compression applied, such as an elastic bandage. Some cases may require one or more injections of corticosteroids into the bursa to relieve inflammation, although most experts consider cortisone injection anywhere near the Achilles tendon as contraindicated since it may predispose Achilles tendon rupture.

In rare cases in which tendinitis persists and does not respond to non-surgical treatment, removal of unhealthy tissue (débridement) of the Achilles tendon may be suggested. The ankle is then placed in a cast until healing takes place (about 6 to 8 weeks). Once the cast is removed, the individual begins physical therapy to restore strength and mobility of the ankle and lower leg.

Prognosis In general, Achilles tendinitis resolves completely following a period of rest, use of anti- inflammatory medications, and splinting or casting if necessary. Acute bursitis may progress to chronic or long-term bursitis and result in limitations of ankle or foot range of motion. Surgical debridement of the tendon generally has a good outcome but carries common surgical risks.

Specialists  Orthopedic (Orthopaedic) Surgeon  Podiatrist  Physical Therapist  Rheumatologist

Rehabilitation An important step in the rehabilitation of Achilles bursitis or tendinitis is to modify any risk factors that are associated with the occurrence of this condition, including poor ankle flexibility, biomechanical abnormalities of the lower limb, and training errors in sports activities such as practicing on a hard running surface or wearing worn out shoes. Achilles bursitis is an inflammation of the retrocalcaneal bursa. Achilles tendinitis can affect the tendon itself, the overlying sheath, or both. The initial goal of the rehabilitation is to decrease pain and inflammation. Later, the aim is to restore function and prevent reoccurrence of the condition.

Initially, it is recommended to follow the PRICE principle (protection, rest, ice, compression, elevation). Modification of activities should always be part of the initial treatment. A soft heel pad in the individual's shoe can reduce pressure on the Achilles tendon and the bursa. As soon as pain and inflammation are reduced, the individual should be instructed in a home program of stretching and strengthening exercises. Heat and cold may be used for pain management. Injection of steroids into the surrounding tendon tissue remains controversial. Although injection may provide pain relief, it weakens the Achilles tendon, increasing the risk of a tendon rupture.

6 Additional information may provide greater insight into the rehabilitation needs of individuals with Achilles bursitis or tendinitis.

Frequency of Rehabilitation Visits Non-surgical Specialist Achilles bursitis or tendinitis Physical Therapist Up to 10 visits within 6 weeks The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Comorbid Conditions  Infection introduced through broken skin at the time of injury  Rheumatoid arthritis  Strain or sprain of the lower leg muscles

Complications Possible complications include rupture of the tendon and symptom recurrence.

Factors Influencing Duration Factors that may lengthen disability include the type, cause, and severity of the injury; the type of treatment provided; the individual's response to treatment; the development of complications; and the individual's compliance with treatment recommendations

Length of Disability

Supportive Treatment, Achilles bursitis or tendinitis Duration in Days Job Classification Minimum Optimum Maximum Sedentary 0 3 14 Light 0 3 14 Medium 0 7 28 Heavy 7 14 42 Very Heavy 7 14 42

Return to Work If casting is required, temporary transfer to sedentary duties may be necessary for individuals with jobs that require prolonged standing, walking, climbing, or lifting. Accommodations may need to be made during this usually short recovery period.

Individuals with chronic conditions should be permanently reassigned to jobs that do not require prolonged standing, walking, climbing, or lifting.

7 Failure to Recover If an individual fails to recover within the maximum duration expectancy period, the reader may wish to reference the following questions to assist in better understanding the specifics of an individual's medical case.

Regarding Diagnosis  Was this a recurring injury?  Was diagnosis confirmed with x-ray, diagnostic ultrasound, or MRI?  Was synovial fluid aspirated and examined microscopically?  Was the fluid cultured to differentiate between infection and inflammation?

Regarding Treatment  If underlying infection was identified, how was it treated?  Has infection resolved?  Was surgery indicated? Was surgery performed?  Were anti-inflammatory drugs used to reduce inflammation?  Did individual receive physical therapy and instruction on stretching exercises?  Did individual use a cane or crutch?

Regarding Prognosis  Did injury occur by a direct blow, or is it due to a sprain or strain?  Did individual return to work or activities too soon?  Was individual adequately instructed in how to modify activities?  Did individual wear protective strapping or adhesive bandage for several weeks after healing?  Was individual instructed in prevention techniques (warm up before activity, proper moves and techniques for that activity, physical conditioning)?

Medical Codes ICD-9-CM: 726.7, 726.71, 726.72 ICD-10: M76.6, M76.9

Heel Spurs (Calcaneus) Definition The calcaneus bone is more commonly known as the heel of the foot. A bony growth on the undersurface of this bone is a heel spur (calcaneal exostosis).

The spur can be seen on x-ray and is often discovered when x-rays are done for another reason. Pain in this region is not the result of the spur, but from inflammation of the tissue in the area. Many people have heel spur(s) and do not have pain in the area.

Common causes of pain in the heel include a bruise (contusion) of the fat pad in the heel, plantar fasciitis and inflammatory diseases including Reiter's syndrome.

Heel spurs may also occur at the back (posterior) of the heel, where the edge of the shoe may rub; this is also known as a "pump bump", or a posterior heel spur (calcaneal

8 exostosis). Posterior heel spurs are especially common in young women, in whom the abnormal bony growth is often related to long-term bursitis caused by the pressure of wearing pump-style shoes.

Reference Data Trends

DURATION TRENDS ICD-9-CM: 726.73 Cases Mean Min Max No Lost Time Over 6 Months 766 57 1 210 < 0.1% 2.7%

Percentile: 5th 25th Median 75th 95th Days: 8 26 48 77 146

Medical Codes ICD-9-CM: 726.73, 736.76

Forefoot (Sesamoid, Phalanges) Fracture Definition A fracture of a sesamoid or one or more phalanges of the forefoot is a disruption or break in a bone or bones of the toe.

The term phalanges is the technical medical word for the bones of a toe (or finger). Each individual bone in a toe is called a phalanx. The sesamoid bones in the toes are embedded in a flexor tendon located under the big toe (under the first metatarsal bone in the foot). Sesamoid stress fractures are uncommon, as are acute fractures. The primary cause of sesamoid fractures is overwork and excessive pressure on that area of

9 the foot. A sesamoid fracture can also occur from a fall that hyperextends the toe, with the medial sesamoid bone the most commonly involved.

Broken toes are usually the result of an accident or stubbing the toe. The big (great) toe is the most frequently broken toe. In addition, a hallux valgus deformity may predispose the individual to fatigue fractures of the base of the great toe. Individuals with osteoporosis are at greater risk for toe fractures and stress fractures in general.

Risk Dancers and runners are at increased risk for sesamoid fractures.

Diagnosis History When a toe is fractured, the individual will complain of pain and tenderness over the fracture site and may relate an injury to the area. The individual will also complain of increased pain upon walking or weight bearing. For a sesamoid fracture, the individual will complain of either dull, intermittent pain in the general area of the sesamoids or severe throbbing pain in that area. The individual may equate the sensation to feeling bruised when walking with a stone in his or her shoe.

Physical Exam Upon examination of a toe fracture, there may be swelling, bruising, numbness, or tingling of the toe. If the fracture is displaced, the toe will have a misshapen or deformed appearance. Upon examination of a sesamoid fracture, there will be pain upon pressing (palpation) in the area of the sesamoids. Pulling on the great toe (distraction) will also cause discomfort.

Tests Routine x-rays will reveal fractures of the toes with special views required for confirming sesamoid fractures. Dislocations may be subtle, and comparison views of the other foot may be necessary. Post-reduction and follow-up films will be taken after dislocation. X- rays of stress fractures may initially be negative, with bony changes only visible after 3 to 5 weeks ("Common Painful Foot Syndromes").

10 Treatment Non-displaced fractures of the phalanges may be treated with "buddy taping." This requires padding and taping the toes together for support and to limit joint motion. Elevation of the foot is an important part of the treatment. Open-toed, semi-rigid shoes are usually most comfortable. A fracture brace or a walking cast with a toe-plate may be used. Crutches may be necessary as weight bearing may be greatly limited early in treatment. Displaced fractures and fractures with dislocation will often require reduction under local anesthesia. If the fracture is unstable, internal fixation may be used, especially in the great toe. Long periods of elevation will be recommended to reduce swelling and the risk of complications. Treatment of these fractures usually includes a walking boot or cast, and crutches with protected weight bearing for 6 to 8 weeks.

Fractures of the sesamoid are treated with rest, anti-inflammatory medications, protective padding, a semi-rigid soled shoe, and arch supports to relieve tension on the flexor hallucis longus tendon. Partial weight bearing may be required for a few days to weeks. If symptoms persist for 6 months after a sesamoid fracture, are unrelieved by a cortisone injection, and cause functional disability, the sesamoid may be surgically removed (excised).

Prognosis Non-displaced, uncomplicated fractures can be expected to heal in 6 to 8 weeks without residual damage. During that time, the ability to walk may be severely impaired. Recovery from fractures that require reduction and fixation may take several weeks, as does associated soft tissue damage. Complications of the injury will extend the recovery period and may have a less successful outcome. Following conservative treatment of a sesamoid fracture, individuals may begin to resume bearing weight. Stiff-soled shoes should be worn until pain is gone. Following a sesamoid fracture, dancers and athletes may require a full year for complete recovery

Specialists  Orthopedic (Orthopaedic) Surgeon  Orthotist  Podiatrist  Physiatrist  Physical Therapist  Sports Medicine Internist

Rehabilitation Toe and sesamoid fractures typically should not require rehabilitation or impede activities of daily living. Elite athletes with great toe fractures are the exception. If rehabilitation is necessary, then the goal is to return the individual to full function with a painless, mobile foot. The duration of treatment is related to possible soft tissue involvement and to the type of fracture. Protocols for rehabilitation must be based upon stability of the fracture and fracture management (operative, nonoperative).

Modalities such as cold and compression wrapping may be used when necessary to

11 control pain and edema. Gait training using appropriate assistive devices is indicated to promote independent ambulation. When indicated, the physical therapist progresses the individual's range of motion and proprioceptive and strengthening exercises until a normal gait and full function are evident. Orthotics may be indicated in some cases to protect the foot, relieve discomfort and promote a functional gait pattern.

If operatively managed, the protocol of rehabilitation will be dictated by the treating physician.

Additional information may yield greater insight into the rehabilitation for forefoot fractures.

Frequency of Rehabilitation Visits Non-surgical* Specialist Fracture, forefoot (sesamoid, phalanges) Physical Therapist Up to 10 visits within 6 weeks *Note on Non-surgical Guidelines: Rehabilitation may not begin until tissue healing, about 6 to 8 weeks after the fracture. The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Comorbid Conditions  Bursitis  Calcium deficiency  Degenerative arthritis  Diabetes  Obesity  Osteoporosis  Peripheral vascular disease  Sesamoiditis  Tendinitis

Complications Because many of these fractures are associated with crushing trauma to the forefoot, extensive soft tissue damage may be the greater problem. Infection, tendon and nerve destruction, and vascular compromise may complicate the injury and treatment. Fracture-dislocation, especially of the great toe, is more challenging to treat. Any underlying medical condition that affects circulation of the foot will complicate treatment. As with all fractures, osteoarthritis and osteomyelitis are possible complications.

Factors Influencing Duration Type and severity of fracture, age, complications of the injury, ability to modify work activities, and rate of healing may affect disability periods. For toe fractures, duration depends on which digit is involved.

12 Length of Disability

Fracture, phalanges of foot Duration in Days Job Classification Minimum Optimum Maximum Sedentary 1 3 14 Light 3 7 21 Medium 14 21 28 Heavy 28 35 42 Very Heavy 28 35 42

Fracture, sesamoid bones Duration in Days Job Classification Minimum Optimum Maximum Sedentary 1 2 3 Light 1 3 7 Medium 3 7 14 Heavy 35 49 84 Very Heavy 42 49 112

Reference Data Trends

DURATION TRENDS ICD-9-CM: 826, 826.0 Cases Mean Min Max No Lost Time Over 6 Months 1829 28 1 122 < 0.1% 0%

Percentile: 5th 25th Median 75th 95th Days: 6 12 21 38 77

Differences may exist between the duration tables and the reference graphs. Duration tables provide expected recovery periods based on the type of work performed by the individual. The reference graphs reflect the actual experience of many individuals across the spectrum of physical conditions, in a variety of industries, and with varying levels of case management. Selected graphs combine multiple codes based on similar means and medians.

Return to Work Restrictions may include partial or non weight-bearing on the affected limb and limited walking, climbing, and squatting. Use of assistive devices such as a cane, crutches, or walker may be necessary. When injuries are severe or involve soft tissue damage to both feet, a wheelchair may be necessary to provide elevation and restricted weight bearing. Accommodations may include frequent rest periods in a facility to allow the individual to lie down with the foot elevated. It should be noted that while the injury may appear trivial, the pain and restriction of activity can be quite dramatic. Temporary work restrictions may be necessary due to special footwear requirements.

Failure to Recover If an individual fails to recover within the maximum duration expectancy period, the reader may wish to reference the following questions to assist in better understanding the specifics of an individual's medical case.

Regarding diagnosis:  Were the individual's presenting symptoms consistent with a diagnosis of forefoot fracture?  Was diagnosis confirmed with x-rays?  If diagnosis was uncertain, were other conditions ruled out?  Is individual obese?  Does individual have degenerative arthritis of the feet, osteoporosis, calcium deficiency, tendinitis, bursitis, sesamoiditis, diabetes, or peripheral vascular disease? Regarding Treatment  Was treatment appropriate for the type of fracture?  Was surgery required?

14  Was pain managed effectively with anti-inflammatory medications?  If not, were other pain management interventions tried?  Is rehabilitation required?

Regarding Prognosis  Has adequate time elapsed for recovery?  Have appropriate accommodations and job reassignments been made?  Did individual suffer any complications that could impact recovery?

Medical Codes ICD-9-CM: 825.29, 825.39, 826, 826.0, 826.1 ICD-10: S82.8, S92.2, S92.3, S92.4, S92.5, S92.7, S92.9

Metatarsal Bones Fracture Definition A metatarsal bone fracture is a break in one of the five metatarsal bones in each foot. These long thin bones are located between the toes and the ankle (between the tarsal bones in the hindfoot and the phalanges in the forefoot). Most stress fractures involve the lower extremities; the metatarsals are the most common site.

Fractures of the metatarsal bones are often associated with dislocations and are often unstable. They are classified by their location: head, shaft/neck, or base. The most common fracture is of the base of the fifth metatarsal, and is the result of twisting the forefoot. The location must be carefully evaluated as the treatment is radically different from fractures of the shaft of the fifth metatarsal. Fractures may develop in the metatarsals from repetitive use as well as from acute injury. More force is placed on the second and third metatarsals when ambulating; therefore, stress fractures and bone remodeling from stress are common in the second or third metatarsal.

Most metatarsal fractures are caused by twisting injuries or direct impact. Athletes, individuals who are obese, and individuals with osteoporosis or rheumatoid arthritis have an increased risk of metatarsal fractures.

Risk Individuals involved in running, ballet, gymnastics, and high-impact aerobic activities are at increased risk of fractures and stress fractures of the metatarsals.

Diagnosis History Individuals will report sharp pain in the forefoot that is aggravated by walking. Individuals may also report swelling (edema) and discoloration of the skin (ecchymosis). Most individuals will report a trauma prior to the beginning of the symptoms. Stress fractures will not be associated with a single trauma but rather with an increase in intensity or duration of repetitive activity like jogging, ballet dancing, etc.

Physical Exam The foot may appear swollen over the suspected fracture site, deformity may be apparent, and pain will usually be localized. With severe injuries, soft tissue damage may be apparent. Forefoot motion will be limited by pain. In more chronic cases, pain may be more diffuse and swelling minimal.

Tests Routine x-rays (AP, lateral, and oblique views) are usually sufficient to diagnose the fracture. Comparison views of the other foot may be necessary. CT scans or MRI may be needed to rule out other injuries. Because plain film radiographs are frequently unrevealing for stress fractures, a bone scan can potentially reveal the earliest sign of a stress fracture. A particular bone scan method called triple phase nuclear medicine bone scan is often used as well as magnetic resonance imaging for confirming the diagnosis.

Treatment Non-displaced fractures of the shaft are the least difficult to manage. Treatment for minor metatarsal fracture will include RICE therapy (rest, ice, compression, and elevation). Conservative treatment for minor metatarsal fractures will continue with a stiff-soled shoe, fracture brace, or walking cast. More severe fractures may require a non-weight bearing cast for several weeks. Displaced fractures may require open reduction and fixation. In areas of the foot where there is poor blood supply or in cases of significant dislocation, surgery (open reduction and internal fixation; ORIF) may be necessary.

16 Prognosis A good outcome can be expected for simple, non-displaced fractures without complications. Healing usually is noted within 6 to 8 weeks. Complicated fractures with associated injuries (e.g., dislocations) that require surgery will take longer to heal and the outcome may be less successful, especially if treatment has been delayed and circulation compromised.

Specialists  Orthopedic (Orthopaedic) Surgeon  Orthotist  Podiatrist  Physiatrist  Physical Therapist  Sports Medicine Internist

Rehabilitation The duration of treatment of a fracture of the metatarsal bones is related to the location and type of fracture, and fracture management. Weight bearing, as advised by the treating physician, may enhance healing and can minimize rehabilitation requirements. Resumption of pre-injury status is the goal with consideration of any residual deficit. Protocols for rehabilitation must be based upon stability of the fracture and fracture management (operative, nonoperative).

The goal of rehabilitation is to decrease pain and to return the patient to full function with a painless foot. If the injury is managed conservatively and not casted, the individual should follow the PRICE (protection, rest, ice, compression, elevation) procedure until the swelling is stabilized (up to 48 hours). Gait training using appropriate assistive devices is indicated to promote independent ambulation. Begin gentle range of motion, stretching and strengthening exercises when the fracture is stable. The individual may be instructed in home exercises to be performed in conjunction with supervised rehabilitation. Progress exercise intensity as indicated until full function is achieved.

If initially immobilized, after the cast is removed, therapy should begin with range of motion, strengthening and proprioceptive exercises of the involved lower extremity, proceeding with the activities recommended for a non-casted case. There is some evidence to suggest that resumption of pre-injury activity level is faster when managed with a soft dressing as compared with a cast. Following management with a cast or soft dressing, use of orthotics may be beneficial for some individuals.

Bone healing may occur within 6 to 12 weeks; however the bone strength and the ability of the bone to sustain a heavy load may take up to several years. Once healing has occurred, the individual may resume full activities of daily living. It is important to inform the individual not to overload the fracture site until the bone has regained its full strength. The resumption of heavy work and sports should be guided by the treating physician.

17 Frequency of Rehabilitation Visits Non-surgical* Specialist Fracture, metatarsal bones Physical Therapist Up to 12 visits within 6 weeks Surgical Specialist Fracture, metatarsal bones Physical Therapist Up to 6 visits within 4 weeks *Note on Non-surgical Guidelines: Rehabilitation may not begin until tissue healing, about 6 to 8 weeks after the fracture. The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Comorbid Conditions  Avascular necrosis  Compartment syndrome  Obesity

Complications Compartment syndrome, soft tissue damage, and infection may complicate the injury. Nonunion, infection, loss of reduction, or compartment syndrome could be complications of treatment. Chronic pain, callus growth on the sole of the foot, and traumatic degenerative arthritis could be long-term complications of the injury. Dislocation of the metatarsal-tarsal joint(s) associated with metatarsal fracture(s) is a more severe injury with longer recovery times and with a greater likelihood of permanent pain. The dislocation component of this injury can be subtle on x-ray and at times is not recognized, leading to a poor result.

Factors Influencing Duration The type and severity of the fracture, associated injuries, treatment required, whether surgical intervention was necessary with or without the use of internal or external fixation, and response to treatment may affect the length of disability. The ability to modify work requirements and the rate of healing may also affect the disability period.

Length of Disability

Fracture, proximal 5th metatarsal (Jones fracture) Duration in Days Job Classification Minimum Optimum Maximum Sedentary 1 2 3 Light 1 2 3 Medium 14 21 28 Heavy 35 42 56 Very Heavy 35 42 56

18 Stress Fracture, 2nd or 3rd metatarsal Duration in Days Job Classification Minimum Optimum Maximum Sedentary 1 1 1 Light 1 2 3 Medium 7 14 21 Heavy 21 28 84 Very Heavy 21 28 84

Fracture, 1st metatarsal Duration in Days Job Classification Minimum Optimum Maximum Sedentary 1 2 3 Light 42 56 84 Medium 70 84 112 Heavy 112 140 168 Very Heavy 112 140 168

Fracture, distal metatarsal 2nd, 3rd, 4th, or 5th (neck) Duration in Days Job Classification Minimum Optimum Maximum Sedentary 7 9 14 Light 21 28 35 Medium 42 49 70 Heavy 70 77 84 Very Heavy 70 77 112

Fracture, metatarsal bone (closed) Duration in Days Job Classification Minimum Optimum Maximum Sedentary 1 7 14 Light 7 14 28 Medium 28 42 70 Heavy 56 70 84 Very Heavy 56 70 112

Reference Data Trends

DURATION TRENDS

ICD-9-CM: 825, 825.25

19 Cases Mean Min Max No Lost Time Over 6 Months 2238 57 0 227 0.1% 1.5%

Percentile: 5th 25th Median 75th 95th Days: 10 29 49 74 132

DURATION TRENDS ICD-9-CM: 825.2 Cases Mean Min Max No Lost Time Over 6 Months 2269 41 1 161 < 0.1% 0%

Percentile: 5th 25th Median 75th 95th Days: 7 21 35 54 105

Return to Work Weight bearing may be restricted for several weeks. This will affect the individual's ability to climb stairs or ladders, stand for even short periods of time, stoop, squat, or walk short distances. Crutches, canes, walkers, or wheelchairs may be required. Periods of time to elevate the foot to control edema (swelling) may be required. Safety issues concerning work in confined space, limited dexterity, and ability to ambulate should be reviewed. The individual may be unable to drive for a period of time until lower extremity weight bearing is allowed as well as adequate foot, ankle and the associated lower extremity muscle control is demonstrated. Frequent rest periods with the ability to elevate and ice the lower extremity may be necessary.

Temporary work restrictions may be necessary due to special footwear requirements.

21 Failure to Recover If an individual fails to recover within the maximum duration expectancy period, the reader may wish to reference the following questions to assist in better understanding the specifics of an individual's medical case.

Regarding Diagnosis  If diagnosis was uncertain after plain x-rays, was a bone scan considered to rule out a stress fracture?  Did the individual present with symptoms consistent with a metatarsal bone fracture? Was the diagnosis confirmed with an x-ray?  If the diagnosis was uncertain, were other conditions with similar symptoms ruled out?  Does the individual have any condition that might impact ability to recover?

Regarding Treatment  Was the treatment appropriate for the type of fracture?  Was surgery required? Are the weight bearing ends of all five metatarsals on the same level, or is one or more of the metatarsals healed in poor position causing pain and calluses on the bottom of the foot?  Would the individual benefit by consultation with a specialist (orthopedic surgeon, podiatrist, sports medicine specialist, or physiatrist)?

Regarding Prognosis  Has individual followed prescribed rehabilitative therapy?  Did the individual suffer any complications that may impact ability to recover?  Have appropriate work reassignments and accommodations been made?

Medical Codes ICD-9-CM: 825, 825.2, 825.25 ICD-10: S92.2, S92.3, S92.4, S92.5, S92.7, S92.9

Midfoot (cuboid, cuneiform, Navicular) Fracture Definition A midfoot fracture is a fracture of one or all of the bones in the midfoot (navicular, cuboid, and cuneiform). Fractures of the bones in the midfoot are usually not isolated injuries; there are often multiple fractures or fracture-dislocations. The midfoot is fairly rigid and stable, and when injuries occur, the force is often transmitted across the rows of bones.

Navicular fractures are the most common midfoot fractures (62% of all midfoot fractures). Navicular fractures are classified as dorsal avulsion fractures, tuberosity fractures, non-displaced body fractures, displaced body fractures, or osteochondral fractures. Dorsal avulsion fractures are the most common navicular fracture, accounting

22 for 47% of all navicular fractures.

Cuboid fractures can occur in isolation but are more often seen in conjunction with other fractures. Cuboid fractures are classified as avulsion (most occur on the lateral side) or body fractures (may be simple, stress, comminuted, crush, or fracture/dislocation).

Cuneiform fractures are classified as avulsion fractures, body fractures, or fracture- dislocations. Of the three cuneiform bones, the medial cuneiform bone is the most commonly injured.

Lisfranc fractures are fractures-dislocations at the tarsometatarsal joint. These are more common in individuals with diabetes and may occur following a direct impact or forced twisting of the foot.

Risk Athletes, especially runners, jumpers, and sprinters, are at risk for midfoot stress fractures.

Women are more at risk for stress fractures than men, particularly when activity is abruptly increased. Approximately 60% of both men and women who have had a midfoot stress fracture are likely to have a recurrent fracture (Sanderlin).

Individuals with a long second metatarsal/short first metatarsal have increased risk for developing a stress fracture of the navicular bone due to altered force transmission during toe-off.

Incidence and Prevalence Midfoot fractures are rare, with only about 0.5% of all fractures involving the midfoot. Navicular stress fractures make up 14% to 35% of all stress fractures. The incidence of Lisfranc fracture-dislocation is approximately 1 per 55,000 persons per year

Diagnosis History The individual usually reports marked pain and swelling and limited ability to move the

23 foot and bear weight. There may be open wounds or severe soft tissue damage if the fractures result from a crushing injury.

Physical Exam Localized pain, swelling, and possible deformity may be noted. Attention must be paid to skin integrity and neurovascular status. The exam must rule out dislocations of the metatarsal bones, because they are commonly associated injuries.

Tests Anterior-posterior (AP), lateral, and oblique x-rays with comparison views from the other foot are necessary, because these fractures are often difficult to detect due to overlapping bone outlines. A CT scan may be necessary to confirm the diagnosis. Bone scans are nearly 100% sensitive for navicular stress fractures.

Treatment Depending on the type of fracture, treatment may range from a weight bearing fracture brace or cast until the individual is asymptomatic (approximately 3 weeks) to open reduction and internal fixation (ORIF) followed by a non-weight bearing cast until the bones have healed. Unstable, comminuted, or displaced fractures that cannot be simply reduced are treated surgically, as are fracture-dislocations.

Prognosis The outcome depends on the severity of the fracture, the treatment required, and the development of complications. Non-displaced fractures generally have an excellent prognosis with appropriate treatment. In fractures severe enough to require surgery, healing times may be extended by 1 to 3 weeks, but the overall outcome is still good. Specialists  Orthopedic (Orthopaedic) Surgeon  Physiatrist  Physical Therapist  Sports Medicine Internist

Rehabilitation The duration of treatment for a midfoot fracture is related to the location and type of fracture and the length of immobilization. The main focus of rehabilitation should emphasize restoring full range of motion, strength, proprioception, and endurance while maintaining independence in all activities of daily living. Resumption of pre-injury status is the goal with consideration of any residual deficit of the foot or ankle. Protocols for rehabilitation must be based upon stability of the fracture and fracture management (operative, nonoperative).

The goal of rehabilitation is to return the full function with a painless foot. Modalities such as cold may be beneficial for controlling pain and edema. This type of fracture typically may not impede activities of daily living, but it may interfere with the individual's ability to work due to pain and restricted weight bearing. Gait training using appropriate assistive devices will help the individual walk and move about independently; weight bearing should progress as indicated by the treating physician. When indicated, the

24 physical therapist progresses the range of motion and proprioceptive and strengthening exercises until a normal gait and full function is evident. The individual may be instructed in home exercises to be performed in conjunction with supervised rehabilitation. Orthotics may be indicated in some cases to protect the foot, relieve discomfort and promote a functional gait pattern.

Bone healing may occur within 6 to 12 weeks, but bone strength and the ability of the bone to sustain a heavy load may take up to several years to return. Once healing has occurred, the individual may resume full activities of daily living. It is important to inform the individual not to overload the fracture site until the bone has regained its full strength. The resumption of heavy work and sports should be guided by the treating physician. Frequency of Rehabilitation Visits Non-surgical* Specialist Fracture, midfoot (cuboid, cuneiform, navicular) Physical Therapist Up to 15 visits within 6 weeks Surgical Specialist Fracture, midfoot (cuboid, cuneiform. Navicular) Physical Therapist Up to 12 visits within 6 weeks *Note on Non-surgical Guidelines: Rehabilitation may not begin until tissue healing, about 6 to 8 weeks after the fracture. The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. Comorbid Conditions  Avascular necrosis  Compartment syndrome  Diabetes  Obesity  Osteoarthritis  Osteomyelitis  Peripheral vascular disease

Complications Compartment syndrome is the most dangerous acute complication of midfoot fractures. Compartment syndrome is most commonly associated with fractures sustained from a crushing injury. Long-term complications of midfoot fractures include infection, degenerative arthritis, nonunion or instability, and gait disturbances.

Factors Influencing Duration The type and severity of fracture, the individual's age, any complications of the injury, the individual's ability to modify work activities, and the rate of healing may affect disability periods

25 Length of Disability

Tuberosity fracture, navicular bone of foot Duration in Days Job Classification Minimum Optimum Maximum Sedentary 7 10 14 Light 7 14 21 Medium 14 21 42 Heavy 14 28 56 Very Heavy 21 42 56

Dorsal avulsion fracture, navicular bone of foot Duration in Days Job Classification Minimum Optimum Maximum Sedentary 1 2 3 Light 1 2 3 Medium 14 21 28 Heavy 28 35 56 Very Heavy 28 35 56

Body fracture, navicular bone of foot (non-displaced) Duration in Days Job Classification Minimum Optimum Maximum Sedentary 1 2 3 Light 1 2 3 Medium 21 28 112 Heavy 70 77 168 Very Heavy 70 77 224

Stress fracture, navicular bone of foot Duration in Days Job Classification Minimum Optimum Maximum Sedentary 1 3 7 Light 14 21 28 Medium 56 63 112 Heavy 84 112 168 Very Heavy 84 112 168

Body fracture, navicular bone of foot (displaced) Duration in Days Job Classification Minimum Optimum Maximum Sedentary 7 9 14 Light 42 49 56 Medium 56 63 112 Heavy 112 126 168 Very Heavy 112 126 224

Fracture, cuboid or cuneiform bone of foot Duration in Days Job Classification Minimum Optimum Maximum Sedentary 1 2 3 Light 1 2 3 Medium 14 28 42 Heavy 42 56 84 Very Heavy 56 70 112

Return to Work Weight bearing may be restricted for several weeks, which will affect the individual's ability to climb stairs and ladders, stand for even short periods, or walk short distances. Crutches, canes, walkers, or wheelchairs may be required. Stooping and squatting should be restricted until the individual has regained full range of motion through stretching and physical therapy. Safety issues concerning working in a confined space, with limited dexterity, and with a limited ability to ambulate should be reviewed. Frequent rest periods that allow the individual to elevate the lower extremity may be necessary.

Regarding Diagnosis  Has diagnosis been confirmed by x-ray and CT scan?  Is Lisfranc tarsal-metatarsal fracture-dislocation present but unrecognized?  Has individual experienced any complications related to fracture or treatment?  Does individual have an underlying condition, such as diabetes, peripheral vascular disease, obesity or other conditions that may affect recovery?

Regarding Treatment  Was individual placed in a cast?  Was surgical intervention necessary?  Is individual active in physical therapy?  Is individual compliant with weight-bearing restrictions?

Regarding Prognosis  If symptoms persist past expected recovery, have x-rays been repeated to rule out nonunion or malunion?  Are other complications present?  Is individual following prescribed rehabilitative therapy?  Has individual resumed weight-bearing too soon?

27 Medical Codes ICD-9-CM: 825.22, 825.23, 825.24 ICD-10: S92, S92.1, S92.2, S92.3, S92.7, S92.9

Plantar Fasciitis Definition Plantar fasciitis is the painful condition that results when the thick, fibrous band on the sole of the foot, which extends from the bottom of the heel bone (calcaneus) to the base of the toes (plantar fascia), becomes irritated and swollen (inflamed). Plantar fasciitis is the most common cause of heel pain.

The plantar fascia functions like a thick rubber band on the bottom of the foot to hold the many foot bones in place, and thus support the arch of the foot.

Inflammation and/or degeneration of the plantar fascia result from mechanical strain (traumatic fasciitis), from abnormalities of foot structure (biomechanical plantar fasciitis), from systemic inflammatory diseases, or from unknown causes. Foot pain caused by plantar fasciitis may occur in several locations: (1) along the entire course of the plantar fascia due to microtears in the band; (2) at the plantar fascia's point of attachment into the calcaneus; (3) along the inside edge of the arch (medial band plantar fasciitis); (4) in the middle of the arch (central band plantar fasciitis); or (5) or along the outer edge of the arch (lateral band plantar fasciitis). Although both feet may be involved (bilateral), most cases involve only one foot (unilateral).

Some cases of plantar fasciitis are the result of a biomechanical fault that causes abnormal rotation of the foot's arch upward (pronation).

Risk The condition is most common in groups of people who strain their feet, including runners and other athletes, those with jobs that require a lot of walking or standing, and among those with sudden weight gain—either by lifestyle habits or pregnancy, although the strength of association is weak. Most cases are of unknown origin (idiopathic).

Plantar fasciitis occurs most commonly in individuals between 40 and 70 years of age.

Diagnosis History The individual may complain of pain in the bottom of the heel or in the arch. Characteristically, the pain is at its worst when taking the first few steps after having been sitting or lying for a while. Pain is usually worse in the morning and improves with movement throughout the day. At the end of the day, the pain may change to a dull ache that improves with rest. Pain is worse when the individual is barefooted, and improves with shoes.

28 Physical Exam Typical physical exam findings include tenderness upon touch (palpation) on the bottom of the heel, closer to the midline, and mild swelling and redness. Bending the foot toward the shin (ankle dorsiflexion) may increase the pain, especially if the toes are simultaneously hyperextended.

Tests X-rays may rule out other conditions, show increased soft tissue density of the plantar fascia, or reveal a bone spur on the sole portion of the heel bone (plantar calcaneal tuberosity). If present, the spur is unrelated to the plantar fasciitis. A bone scan may show increased activity in the heel.

Treatment Plantar fasciitis usually responds to conservative (non-surgical) treatment. About 90% to 95% of individuals improve within 9 months without surgery (Chen). Treatment may consist of ice packs, Achilles tendon stretching exercises, heel pads or heel cups, over- the-counter arch supports, prescription arch supports (orthotics), heel lift if due to limb length inequality, physical therapy, anti-inflammatory medications, injections of corticosteroid medication into the heel area, full foot taping, night splints, casting, or crutches. Sometimes a splint is worn at night to stretch out the plantar fascia. Weight loss is essential if the individual is obese.

Although conservative treatment is effective, it can often take several weeks or even months for the pain to resolve. Some type of shoe insert (heel pad or cup, arch support, or orthotic) is usually necessary after treatment to prevent recurrence.

Shockwave therapy is the next step for patients that do not respond to conservative treatment. High-energy shockwaves breakup damaged tissue and increase blood flow. One to two treatments may be necessary over an 8 week period.

Steroid injections provide lasting relief in about 50% of people. However, this injection is very painful.

Surgery is required in only a few cases (5% or less) of severe plantar fasciitis that do not respond after a lengthy period of conservative treatment ("Plantar Fasciitis"). Considerable controversy exists regarding whether to operate on these individuals, and which of several procedures to use. Some surgeons advocate cutting the tight fascia to relieve the tension, while others resect the heel spur and detach the plantar fascia. Recently, some surgeons have performed a plantar fascia release (plantar fasciotomy) through an endoscope (endoscopic plantar fasciotomy; Barrett procedure) with a high success rate.

Prognosis The pain in most cases of plantar fasciitis resolves completely, although it may be a chronic condition. Some individuals will need to wear orthotics permanently to prevent

29 symptom recurrence. Most individuals treated surgically obtain reduction (70% to 90%), but not resolution, of pain.

Specialists  Orthopedic (Orthopaedic) Surgeon  Physiatrist  Podiatrist

 Physical Therapist  Rheumatologist

Rehabilitation Because plantar fasciitis is a self limiting disease, it usually resolves within a nine-month period, with residual symptoms in about 10% of all cases. The condition becomes chronic if pain persists for longer than 6 months. A variety of treatments are commonly implemented to treat plantar fasciitis with many of these treatments unsubstantiated by sound scientific evidence. Common treatments include exercise, ultrasound, night splints, and custom and standard orthotics. Injections are also used as treatment.

Exercises emphasizing stretching of the Achilles tendon are commonly prescribed. For greater benefit, a plantar fascia tissue stretching program should be utilized. Orthotics are commonly used to provide external support to the foot in an anatomically proper alignment. Some evidence exists supporting the use of prefabricated supports over custom orthotics, while no clear evidence indicates the benefit of custom devices. A combination of stretching and shoe inserts has yielded the most favorable results. Cushioned insoles with active bipolar magnets have not been shown to have any therapeutic value.

To date, no randomized controlled trials exist to support the use of ultrasound or resting night splints as part of the rehabilitation for plantar fasciitis (Probe). Limited evidence supports the use of corticosteroid injections for pain reduction up to 1 month; however the benefits were not lasting.

Frequency of Rehabilitation Visits Non-surgical Specialist Plantar Fasciitis Physical Therapist Up to 12 visits within 6 weeks The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Comorbid Conditions  Arthritis  Obesity

Complications Nerve injury or infection may result from surgery or corticosteroid injections. If

30 corticosteroids are injected into the heel fad pad, this structure may atrophy and make weight bearing more painful.

Factors Influencing Duration Compliance with recommended treatment and activity restrictions, job demands (especially standing and walking requirements), and response to treatment affect the duration of disability.

Length of Disability

Medical Treatment, Plantar Fasciitis Duration in Days Job Classification Minimum Optimum Maximum Sedentary 0 3 7 Light 0 3 7 Medium 1 7 10 Heavy 3 10 14 Very Heavy 3 10 14

Surgical Treatment, plantar fasciotomy Duration in Days Job Classification Minimum Optimum Maximum Sedentary 1 7 14 Light 7 14 21 Medium 14 21 28 Heavy 21 28 42 Very Heavy 21 28 42

Reference Data Trends DURATION TRENDS ICD-9-CM: 728.71 Cases Mean Min Max No Lost Time Over 6 Months 1485 54 1 222 < 0.1% 3.0%

Percentile: 5th 25th Median 75th 95th Days: 8 23 44 73 149

Return to Work Any restrictions or accommodations depend on the severity of the condition. Standing and walking may need to be restricted. If casting or crutches are used postoperatively, the individual will need to limit ambulation and must be allowed to elevate the foot. If orthotics are used, the individual must be allowed to wear enclosed shoes (such as nursing shoes, or work boots) that will accommodate the orthotics.

Regarding Diagnosis  Has diagnosis of plantar fasciitis been confirmed? Has a bone scan ruled out a stress fracture of the calcaneus?  Does individual have an underlying condition such as painful heel spurs, obesity, or arthritis that could impact recovery?

Regarding Treatment  Do symptoms persist despite treatment? Has enough time elapsed for pain to resolve?  If unable to lose weight on his/her own, would individual benefit from enrollment in a community weight loss program?  Is individual a candidate for surgical intervention? By which procedure? Based on what criteria?

Regarding Prognosis  Has enough time elapsed to evaluate effectiveness of treatment?  Would individual benefit from consultation with a podiatrist regarding the entire

32 weight distribution in that foot?  Is individual compliant with preventive measures, such as wearing some type of shoe insert, heel pad or cup, arch support, or orthotic?  Is individual realistic about prognosis expectations?

Medical Codes ICD-9-CM: 728.71 ICD-10: M72.2

Foot Sprains and Strains Definition A sprain or strain of the foot is an injury due to a twisting motion or repetitive stress. A sprain is an injury to a ligament, and a strain is an injury to a muscle or tendon. The severity of injury is dependent on whether the ligament or tendon is stretched or torn, whether the tear is partial or complete, and the number of ligaments or tendons involved. A grade I sprain is mild, with overstretching of the involved ligament and no joint instability. A grade II sprain is moderate, with partial tearing of the ligament and moderate joint instability. A grade III sprain is severe, with a complete tear of the ligament and marked joint instability.

Sprains usually involve the ligaments between the joints of the metatarsals and bones of the midfoot (cuboid, navicular) or the hindfoot (calcaneocuboid). The toe joints are frequently sprained from stubbing the toe, particularly when barefooted. Strains involving the tendons, which can be over stressed with a change in activity level, are more common in the metatarsal region.

Sprains and strains of the foot may be acute or chronic and result from stress over time. Pressure, poor muscle tone, and excessive weight are risk factors because they stretch the support structures and lead to sprains and strains. In more severe sprains and strains, there are often coexistent tendon ruptures or joint dislocations. A particularly difficult sprain to diagnose is that of the ligament between the bases of the first and second metatarsals (sagittal diastasis), a condition often occurring in football players. A third-degree sprain of the foot may result in dislocation, which is a relatively rare occurrence but one with serious consequences.

Risk Sprains occur more commonly in younger individuals (in the second through fourth decade of life) due to trauma or athletic injuries. Acute strains are also seen more commonly in these individuals, while chronic strains, particularly of the medial musculature (tibialis anterior and posterior) and plantar structures (plantar fascia) are usually seen in middle-aged to older individuals, and more often in females, especially those who are obese or those who have chronic inflammatory conditions or tendinitis.

Individuals who have recently changed footwear and/or heel height of their shoes, those who are newly active, or those who must weight bear for prolonged periods of time are more at risk for acute and chronic foot sprains and strains.

33 Incidence and Prevalence Incidence of foot injuries including sprains, strains, fractures, and dislocations is 23 per 1,000 in the US.

Diagnosis History Individuals will report an increase in activity level or duration that preceded the onset of pain. Individuals may complain of swelling. Weight bearing is painful, while rest relieves the pain along the forefoot. There may not have been a specific traumatic episode, although if there was an acute trauma the individual may report feeling a "pop" at the time of injury.

Physical Exam Pain is localized over the ligament or tendon involved. Flexion of the toes or movement of the midfoot or hindfoot may cause pain. Swelling and black-and-blue discoloration (ecchymosis) may be present over the injured area.

Tests X-rays may be taken to rule out any other cause for the symptoms such as stress fractures or avulsion fractures, but are not required.

Treatment Early treatment for foot sprains and strains follows the acronym RICE: rest, ice, compression, and elevation. This treatment is used for the first 2 to 3 days, followed by modified rest and restricted weight bearing. Anti-inflammatory medications may be used to control pain and swelling. In more chronic cases, taping, splints, or prescription in- shoe support devices (orthoses) are useful. Complete tears (third-degree injuries) may require surgical treatment (primary repair or modified Bunnell procedure).

Prognosis Individuals with simple strains and sprains (first-degree) recover completely after treatment with rest, ice, compression, and elevation (RICE). Individuals with partial tears of ligament (sprain) or muscle (strains) recover completely after a period of treatment with taping or splinting. All of these individuals are able to return to work and recreational activities without fear of reinjury. Individuals with complete tears of ligaments, tendons, or muscles (third-degree injuries) eventually heal after treatment with casting or surgery (primary repair or modified Bunnell procedure), but some individuals develop chronic instability and may need to wear prescription in-shoe supportive devices (orthoses) to prevent re-injury.

Specialists  Orthopedic (Orthopaedic) Surgeon  Podiatrist  Physiatrist  Sports Medicine Internist

34 Rehabilitation Individuals who sustain a foot sprain do not usually require lengthy rehabilitation. Rehabilitation should initially focus on pain control and normalizing gait. PRICE (protection, rest, ice, compression, elevation) may be followed for the first 48 hours or until the swelling has stabilized. Temporary use of an assistive device such as cane may be necessary to promote pain-free and normal ambulation. A compressive wrap may be useful for controlling edema and providing some foot stability until healing has occurred. Shock absorbing insoles have been shown to reduce the pressure on the foot and may be beneficial. To date, modalities, such as ultrasound and massage have not been shown to facilitate healing of sprains and strains of the foot.

Once the swelling has stabilized, rehabilitation should focus on range of motion and strength of the ankle, foot, and toes. Early in this phase of treatment, individuals should be instructed in a home exercise program to be continued daily, with all exercises progressed as tolerated. It is important to strengthen both the intrinsic and extrinsic muscles of the foot. Proprioceptive exercises are recommended if unweighting of the foot was a part of treatment (i.e., ambulation with an assistive device).

It should be noted that Lisfranc sprains (at the tarsometatarsal joints) may require more rigid immobilization, in which case rehabilitation would be similar to that for an ankle fracture.

Frequency of Rehabilitation Visits Non-surgical Specialist Sprains and Strains, foot Physical Therapist Up to 6 visits within 2 weeks The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Comorbid Conditions  Obesity  Osteoarthritis  Rheumatoid arthritis

Complications Fracture and dislocation complicate the injury. Joint inflammation or degenerative changes in the ligaments or joints are possible complications of the injury. Chronic foot strain may develop as a complication of an acute or sub-acute episode.

Factors Influencing Duration Extent of the injury, response to treatment, complications, and job demands such as walking, climbing and standing may impact duration of disability.

35 Length of Disability Surgical Treatment, plantar fasciotomy Duration in Days Job Classification Minimum Optimum Maximum Sedentary 1 3 7 Light 1 3 7 Medium 3 7 14 Heavy 3 14 21 Very Heavy 3 21 28 Reference Data Trends

DURATION TRENDS ICD-9-CM: 845.1 Cases Mean Min Max No Lost Time Over 6 Months 789 21 0 97 0.2% 0%

Percentile: 5th 25th Median 75th 95th Days: 3 7 14 28 63

36 Return to Work Activity restrictions may include limited or no weight bearing, limited standing, walking, and squatting. Individuals may use ambulation assistive devices (crutches, cane, or walker). Manual dexterity may be affected by the use of these devices. Use of medication would require review of any drug policies. Driving, including using a clutch, is permitted after the individual has returned to using normal footwear.

Regarding Diagnosis  Have conditions such as plantar fasciitis, Morton's neuroma, metatarsalgia, stress fracture, bursitis, or compartment syndrome, been ruled out?  Has diagnosis been confirmed?  Does individual have continued pain after treatment?  Has a bone scan (scintigram) been done to rule out the presence of an occult fracture, particularly in the midfoot area?  Has individual experienced any complications such as joint inflammation, degenerative changes, associated fracture or dislocation, or chronic foot strain?  Is individual obese?  Does individual have an underlying condition that may impact recovery?

Regarding Treatment  Have all conservative options been utilized?  Has individual been compliant in following prescribed treatment plan, including rest, ice, compression, and elevation used for the first 2 to 3 days, followed by modified rest and restricted weight bearing, and anti-inflammatory medications?  Is surgical intervention warranted?

Regarding Prognosis  Has individual been compliant with RICE treatment, and with taping or splinting if required?  If symptoms have persisted beyond expected recovery, does diagnosis need to be revisited?  Have occult fractures been ruled out?  Would individual with chronic instability benefit from the use of orthotic devices?

Medical Codes ICD-9-CM: 845.1, 845.10, 845.11, 845.12, 845.13, 845.19 ICD-10: S93, S93.2, S93.3, S93.5, S93.6

37 Tests and Treatments Excision of Bone Spurs Definition Excision of a bone spur is the surgical removal of a benign bony growth that projects out of a bone (exostosis or osteophyte).

Bone spurs are caused by abnormal bone growth or imperfect bone remodeling. Bone spurs in the foot most frequently occur in the heel bone (calcaneous), in the ankle joint after a fracture, or on the top of the foot. A bone spur located under a toenail is called a subungual exostosis.

Bone spurs are fairly common conditions, although most do not cause symptoms. Diabetics are more likely to suffer from bone spurs because of their impaired sensation.

Reason for Procedure Foot pain is the primary indication for surgery. Pain may be caused when the bone spur puts pressure on a nerve, especially while wearing shoes. If the bone spur is on top of the foot, excision can be indicated if wearing modified shoes does not relieve pain. A spur may also limit the range of motion of the ankle or bind ("catch") the joint during a certain movement. A bone spur that is causing a wound (ulceration) on the skin (as in a Charcot foot) is usually excised. Bone spur excision is also used to treat heel spur syndrome (plantar fasciitis).

How Procedure is Performed Bone spur excision is usually performed on an outpatient basis. Since the foot is moist and carries a high number of bacteria, special care is taken to prepare for surgery. The foot and lower leg, with particular attention to the toe web spaces, are scrubbed for 8 to 10 minutes with an antibacterial soap. The foot and lower leg are then wrapped in sterile gauze until the individual is on the operating table. Immediately prior to surgery, the foot is washed with an antiseptic solution. Anesthesia may be regional or general. General anesthesia is used for cases in which regional anesthesia is undesirable (for diabetics) and for those in which regional anesthesia has failed. Regional anesthesia can be applied to the forefoot (forefoot or metatarsal block) for excisions in the front of the foot or to the ankle (ankle block) for excisions in the back of the foot (hindfoot). A sedative is often used to relax the individual, both prior to application of the regional anesthesia and during surgery. A tourniquet may be applied to the ankle and foot to reduce blood flow to the foot and allow for a clear work field.

During surgery, the foot is held firmly to prevent motion. At the ankle joint, a bone spur can be excised arthroscopically by use of a drill (burr). Bone spurs on the foot are removed via an open procedure by cutting (incising) into the foot, taking care to avoid damage to nerves and tendons. After the affected bone is exposed, a chisel-like knife (osteotome) is used to remove the spur, and the site is smoothed using a coarse file (rasp). The incision is closed using stitches (sutures).

38 The individual usually wears postoperative shoes designed to accommodate swelling and bulky dressings. Antibiotics and analgesics are used as needed. The individual should rest and elevate the affected limb for 3 to 7 days following surgery.

Prognosis In most cases, bone spur excision succeeds, and the individual experiences a complete recovery and a return to normal function. In only 5% to 6% of cases of subungual exostosis removed by scraping does the bony growth recur (DeLee 2533). Bone spur excision to relieve the pain associated with plantar fasciitis has limited success.

Specialists  Orthopedic (Orthopaedic) Surgeon  Podiatrist  Physical Therapist

Comorbid Conditions  Ankylosing spondylitis  Arthritis  Diabetes  Heart disease  Obesity

Complications Bone spur excision can weaken the bone, which could lead to a fracture. Bone spurs can form again.

Other complications include wound infection, the formation of scar tissue, damage to plantar nerves, accumulation of blood (hematoma), swelling (edema), splitting open of the incision site (dehiscence), deep venous blood clot (thrombus), and superficial vein inflammation caused by a thrombus (thrombophlebitis). Pressure on the local blood vessels from swelling or bleeding can result in compartment syndrome, which can cause permanent muscle and nerve damage. Toenail damage and toenail loss can occur.

Factors Influencing Duration Factors that may influence the length of disability include the number and severity of postoperative complications, success of the surgery, individual's nutritional status and mental and emotional stability, individual's access to rehabilitation facilities and job requirements.

39 Length of Disability Duration will be longer for individuals whose job duties require walking and standing. Surgical Treatment, excision of bone spur (toe) Duration in Days Job Classification Minimum Optimum Maximum Sedentary 1 3 7 Light 1 3 7 Medium 3 7 10 Heavy 3 14 28 Very Heavy 3 14 28 Surgical Treatment, excision of bone spur (heel) Duration in Days Job Classification Minimum Optimum Maximum Sedentary 1 7 14 Light 7 14 21 Medium 14 21 28 Heavy 21 28 56 Very Heavy 21 28 56

Return to Work Prolonged standing or walking may be temporarily limited. Individuals whose work requires standing or walking may need temporary reassignment to a more sedentary position. Operation of a car or other motor vehicle may temporarily be affected. The individual may need to elevate the affected leg and possibly use a cane to walk. He or she may need a parking space closer to the work site.

Medical Codes ICD-9-CM: 77.6, 77.68 CPT®: 28119, 28899

Excision of Morton’s Neuroma Definition A Morton's neuroma is best described as an abnormal growth of tissue resulting from nerve irritation and compression in and around a common digital nerve located between the bases of two adjacent toes. Excision is the removal of this neuroma.

The nerve between the third and fourth toes is most commonly involved, and the nerve between the second and third is the second most commonly involved. Morton's neuroma that involves more than one location on the same foot is extremely rare. The majority of cases do not resolve with conservative treatment, but in 20% to 30% of cases, the condition is successfully treated with non-surgical means, such as footwear modifications and/or corticosteroid injections (Schaller). The remainder may require surgical excision or resection of the digital nerves.

Reason for Procedure Neuroma can cause pain in the foot and toes, especially when walking. If the neuroma is small, symptoms may improve with the use of arch supports, orthotics, low heels and

40 wide toe-boxes in shoes, and/or corticosteroid injections. Unfortunately, the majority of individuals with a Morton's neuroma do not respond to conservative treatment and may require surgery to alleviate symptoms.

How Procedure is Performed The procedure is performed either under general anesthesia, under local anesthesia with conscious sedation, or under local anesthesia with no other sedation. The foot is prepped and draped in the usual manner. Occasionally, a tourniquet is used around the ankle to decrease bleeding during surgery. The skin is then cut (incision), usually on the top of the foot (dorsal surface) over the area of the neuroma. Some surgeons use an incision on the sole of the foot (plantar incision). The incision is then deepened, and the neuroma is visualized. It is then carefully cut out (excised) and is sent to the pathology laboratory for evaluation (pathological examination). The deep tissues and the skin are sewn back together. A surgical dressing is applied, as well as a surgical shoe.

Prognosis Improvement or resolution of painful symptoms is achieved in 20% to 30% of individuals with conservative treatment. Surgical success rates vary in the literature, with "satisfactory" results reported in 75% to 85% of individuals. However, recurrence of the neuroma may be as high as in 50% of all individuals following surgery (Bowman). Individuals will experience residual postoperative numbness in the surgical site and 61% of individuals report residual tenderness.

Specialists  Orthopedic (Orthopaedic) Surgeon

Rehabilitation If the surgeon has used a plantar approach, weight bearing on the operated foot may be painful following surgery, and crutches may be needed for a short period of time. The individual will need to wear a surgical shoe for up to 4 weeks and may need to wear a weight relieving temporary orthosis (fracture brace) and/or shoe insert or metatarsal bar on the outside of the shoe.

Comorbid Conditions  Diabetic neuropathy  Peripheral vascular disease

Complications Complications of the procedure include wound infection, hematoma, wound edge separation (dehiscence), and recurrence of the neuroma. There is loss of cutaneous sensation in the space that was formerly occupied by the neuroma and in the toes beyond it. Other complications include persistent scar sensitivity and residual tenderness. Complex regional pain syndrome (reflex sympathetic dystrophy) may also occur following foot surgery.

Factors Influencing Duration The surgical technique and postoperative treatment vary from surgeon to surgeon and will influence length of disability.

Length of Disability Length of disability depends on job requirements and in some situations, no disability is expected.

Surgical Treatment, excision of Morton’s neuroma Duration in Days Job Classification Minimum Optimum Maximum Sedentary 1 7 21 Light 3 14 21 Medium 3 21 28 Heavy 7 28 35 Very Heavy 7 28 42

Return to Work After surgery the individual will need to avoid prolonged standing or walking. Driving is not permitted with the affected foot. Accommodations may be needed for short-term use of crutches. Due to the use of postoperative pain medications, drug policies should be reviewed.

Medical Codes ICD-9-CM: 04.07 CPT®: 28080

Links to Review: Review all information and additional links

Ankle Foot Surgery

Extracorporeal Shockwave Therapy (Plantar fasciitis treatment)