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Lower Extremity Injury Medical Treatment Guidelines

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Lower Extremity Injury Medical Treatment Guidelines RULE 17, EXHIBIT 6 Lower Extremity Injury Medical Treatment Guidelines Revised: June 24, 2009 Effective: September 1, 2009 Adopted: January 9, 1995 Effective: March 2, 1995 Revised: January 8, 1998 Effective: March 15, 1998 Revised: October 4, 2001 Effective: December 1, 2001 Revised: September 29, 2005 Effective: January 1, 2006 Revised: April 26, 2007 Effective: July 1, 2007 Presented by: State of Colorado Department of Labor and Employment DIVISION OF WORKERS' COMPENSATION TABLE OF CONTENTS SECTION DESCRIPTION PAGE A. INTRODUCTION .......................................................................................... 1 B. GENERAL GUIDELINES PRINCIPLES....................................................... 2 1. APPLICATION OF THE GUIDELINES.............................................................................................. 2 2. EDUCATION ..................................................................................................................................... 2 3. TREATMENT PARAMETER DURATION ......................................................................................... 2 4. ACTIVE INTERVENTIONS ............................................................................................................... 2 5. ACTIVE THERAPEUTIC EXERCISE PROGRAM ............................................................................ 2 6. POSITIVE PATIENT RESPONSE..................................................................................................... 2 7. RE-EVALUATE TREATMENT EVERY 3 TO 4 WEEKS.................................................................... 2 8. SURGICAL INTERVENTIONS.......................................................................................................... 3 9. SIX-MONTH TIME FRAME ............................................................................................................... 3 10. RETURN-TO-WORK......................................................................................................................... 3 11. DELAYED RECOVERY .................................................................................................................... 3 12. GUIDELINES RECOMMENDATIONS AND INCLUSION OF MEDICAL EVIDENCE ....................... 3 13. CARE BEYOND MAXIMUM MEDICAL IMPROVEMENT (MMI) ....................................................... 4 C. INITIAL DIAGNOSTIC PROCEDURES ....................................................... 5 1. HISTORY-TAKING AND PHYSICAL EXAMINATION (HX & PE) ..................................................... 5 a. History of Present Injury............................................................................................................. 5 b. Past History................................................................................................................................6 c. Physical Examination ................................................................................................................. 6 2. RADIOGRAPHIC IMAGING .............................................................................................................. 8 3. LABORATORY TESTING ................................................................................................................. 9 4. OTHER PROCEDURES ................................................................................................................... 9 a. Joint Aspiration......................................................................................................................... 10 D. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES .. 11 1. IMAGING STUDIES ........................................................................................................................ 11 a. Magnetic Resonance Imaging (MRI)........................................................................................ 11 b. MR Arthrography (MRA) .......................................................................................................... 11 c. Computed Axial Tomography (CT)........................................................................................... 12 d. Diagnostic Sonography ............................................................................................................ 12 e. Lineal Tomography .................................................................................................................. 12 f. Bone Scan (Radioisotope Bone Scanning) .............................................................................. 12 g. Other Radionuclide Scanning .................................................................................................. 12 h. Arthrogram ............................................................................................................................... 12 2. OTHER DIAGNOSTIC TESTS........................................................................................................ 12 a. Compartment Pressure Testing and Measurement Devices.................................................... 12 b. Diagnostic Arthroscopy (DA).................................................................................................... 12 c. Doppler Ultrasonography/Plethysmography............................................................................. 13 d. Electrodiagnostic Testing ......................................................................................................... 13 e. Personality/Psychological/Psychosocial Evaluations ............................................................... 13 f. Venogram/Arteriogram............................................................................................................. 14 3. SPECIAL TESTS............................................................................................................................ 14 a. Computer-Enhanced Evaluations............................................................................................. 14 b. Functional Capacity Evaluation (FCE) ..................................................................................... 14 c. Jobsite Evaluation .................................................................................................................... 15 d. Vocational Assessment............................................................................................................ 16 e. Work Tolerance Screening (Fitness for Duty) .......................................................................... 16 E. SPECIFIC LOWER EXTREMITY INJURY DIAGNOSIS, TESTING AND TREATMENT ............................................................................................. 17 1. FOOT AND ANKLE......................................................................................................................... 17 a. Achilles Tendonopothy/or Injury and Rupture .......................................................................... 17 b. Aggravated Osteoarthritis ........................................................................................................ 18 c. Ankle or Subtalar Joint Dislocation........................................................................................... 21 d. Ankle Sprain/Fracture .............................................................................................................. 22 e. Calcaneal Fracture................................................................................................................... 26 f. Chondral and Osteochondral Defects ...................................................................................... 27 g. Heel Spur Syndrome/Plantar Fasciitis...................................................................................... 29 h. Metatarsal-Phalangeal, Tarsal-Metatarsal and Interphalangeal Joint Arthropathy................... 32 i. Midfoot (Lisfranc) Fracture/Dislocation..................................................................................... 34 j. Morton’s Neuroma.................................................................................................................... 36 k. Pilon Fracture........................................................................................................................... 38 l. Posterior Tibial Tendon Dysfunction ........................................................................................ 39 m. Puncture Wounds of the Foot .................................................................................................. 40 n. Severe Soft Tissue Crush Injuries............................................................................................ 41 o. Stress Fracture......................................................................................................................... 43 p. Talar Fracture........................................................................................................................... 44 q. Tarsal Tunnel Syndrome.......................................................................................................... 45 r. Tendonopathy .......................................................................................................................... 47 2. KNEE .............................................................................................................................................. 47 a. Aggravated Osteoarthritis ........................................................................................................ 47 b. Anterior Cruciate Ligament (ACL) Injury .................................................................................
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