Occupational Health Practice Resource Conservative Care Evidence Summary 2015 Industrial Insurance Chiropractic Advisory Committee Conservative Care Options for Work-Related Foot and Ankle Conditions Table of Contents Purpose and Intended Use This resource was developed by the Industrial Insurance Chiropractic Advisory Committee (IICAC) of the Summary Information Washington State Department of Labor and Industries. It provides concise summaries of published clinical • Case Definition and scientific literature regarding utility and effectiveness of commonly used conservative care approaches • Condition & Intervention Summary for work-related foot and ankle conditions; history, examination and special studies, recommendations for • Typical Response Thresholds supportive, manual, and rehabilitative care including practical clinical resources (useable without licensing/charge in practice for non-commercial use). It is intended to inform care options and shared Clinical Resources decision-making. High-level information on invasive treatments is included for informational purposes for • Progress Checklist conservative care providers and not intended as a treatment guideline for such interventions. This document • Foot and Ankle Function Questionnaires is not a standard of care, claim management standard, nor a substitute for clinical judgment in an individual Occupational Foot and Ankle Assessment Summaries case. This practice resource does not change L&I coverage or payment policy, nor does referencing of a research study imply a given procedure is a covered benefit. • History – Diagnostic, Severity & Prognostic Indicators • Clinical Examination – Functional Deficit A comprehensive search of available scientific literature on conservative assessment and intervention • Clinical Examination – Provocation / Relief procedures for foot & ankle conditions was conducted by the Policy, Practice, and Quality (PPQ) • Special Studies and Imaging Subcommittee of the IICAC and department staff during Fall 2014. Literature was reviewed, assessed for • Prognostic Management Indicators relevance and quality and summaries were drafted by consensus of the subcommittee with expert content • Workers’ Compensation Issues input from consultants and reviewers, including the department’s Industrial Insurance Medical Advisory Committee and selected relevant professional societies in June 2015. An updated draft was posted for General Intervention Summaries By Condition public comment and was revised and approved for distribution by the IICAC and department in July 2015. • Sprains This resource is expected to be updated periodically by the IICAC. Interested parties are encouraged to • Tendinosis submit new published scientific reports for consideration for future revisions. • Forefoot/Plantar/Heel Pain This and other practice resources are in the public domain and are available for download at the State of • Joint Dysfunction Washington Department of Labor & Industries website below. Contact information for public input and • Tarsal Tunnel Syndrome submission of studies for future revisions is also available there. • Halux Rigidus • Stress Fractures http://www.Lni.wa.gov/ClaimsIns/Providers/ProjResearchComm/IICAC • Trauma Induced Nerve Syndromes Evidence Summaries By Intervention • Mobilization, Manipulation, Physiotherapeutic Modalities Subcommittee Department Staff Consultants J.F. Lawhead DC Robert D. Mootz, DC Terry Felts, DPM • Exercise Robert Baker, DC Bintu Marong, MS Erik Novak, MD • Orthoses (Bracing, Inserts, Footwear) Linda DeGroot, DC Thomas A. Souza, DC • Other Non-surgical Interventions Michael Neely, DC • Surgical Procedures Overview Michael J. Dowling, DC Additional Materials Acknowledgements • Occupational Foot Condition Terminology IICAC and L&I thank the Washington State Podiatric Medical Association and the • Methodology Physical Therapy Association of Washington for their assistance in reviewing drafts of this • Citations resource, but note that this assistance does not constitute an endorsement. Work-Related Foot and Ankle Conditions PRACTICAL APPLICATION POINTS Ankle sprains are a common work related injury. Fractures, Achilles tendon rupture, • Work-related foot and ankle conditions result from an identifiable injury. With hallux rigidus, and some tendinopathies (with onset closely following a work trauma) may the possible exceptions of metatarsal stress fracture and fat pad syndrome, also result from occupational exposures. Plantar and heel pain are common complaints, conditions related to repetitive stress are unlikely to ever be occupational. however, causation has rarely been associated with work exposure. Pre-existing • Using the Ottawa or Bernese rules to determine indications for x-ray to rule in conditions unlikely to be caused by workplace exposure include biomechanical problems ankle fractures significantly reduces unnecessary (negative) films. (e.g., pronation/supination), chronic ankle instability, and some pain conditions • Stability tests may have limited utility due to inadequate evidence of reliability associated with peripheral neuropathies. Although interventions are individualized for and validity. However, expert opinion encourages stress testing for ligament patients, all treatments and support for injured workers need to be directly related to the damage. accepted work-related condition. • Achilles tendon rupture may typically be determined clinically with calf squeeze and palpation without need for MRI. Evaluation Summary • Functional improvement should be determined using validated functional • tracking instruments at baseline and follow up. Determination and thorough documentation of work-relatedness of foot and ankle • Early mobility and weight bearing to tolerance facilitates a better and faster conditions is crucial for acceptance of an occupational foot or ankle condition, response for lower grade sprains. However a short period of immobilization particularly where onset is not a direct result of an identifiable work injury. • Rule-out potential urgent conditions requiring specialist attention (e.g., fracture, yields faster and more sustained recovery from higher grade sprains. rd • Generally, manual techniques (mobilization, manipulation, soft tissue work) dislocation, tendon rupture, syndesmosis injury, 3 degree sprains). • plus exercise (eccentric stretching) offer better outcomes than exercise alone Rule out infection, vascular compromise, neoplasms, metabolic red flags or electrophysiological modalities for sprains and tendinosis. • Rule-in mechanical components prior to initiating manual care. • Low grade sprains, acute tendinosis, and forefoot pain, typically have a rapid • Document lower extremity function (e.g., validated instruments) at baseline and at initial response to conservative care and resolve within a few weeks. Higher regular follow-up (e.g., 2-3 week intervals). grade sprains, high ankle sprains, and chronic conditions such as chronic plantar pain may take substantially longer to resolve. Intervention Summary • Eccentric exercise facilitates recovery for tendinosis. Neuromuscular exercise • Evidence supports ‘low tech’ approaches such as early mobilization, eccentric may reduce recurrence of ankle sprains. Supervised exercise may offer exercise, manual therapies, and NSAIDs for most straightforward foot and ankle marginal benefit to home programs for higher grade ankle sprain recovery. conditions (sprains, tendinopathy, forefoot pain). • Physiotherapeutic modalities do not add benefit for recovery from most foot • Recovery is typically rapid from sprains (other than high ankle) and most forefoot and ankle conditions. Microcurrent may be helpful in chronic tendinopathy. injuries. Tendinosis and plantar pain tend to respond slower. • Shoe inserts in general may assist in comfort and recovery for foot and ankle • Severe injuries should be managed initially by specialists due to potential difficulty injuries but there do not appear to be advantages for custom made products to identify complications and complexities. over off-the-shelf versions. • Consider reassessment and specialist consult if there is inadequate response within 3-4 weeks of conservative care. Typical Interventions and Approximate Response Thresholds 1-2 wks 3-6 wks 7-8 wks Beyond 8 wks • Initially: Patients with red flags or • Good improvement: Function and weight • Demonstrable improvement should be • Resolution: Most foot & ankle injuries persistent severe pain should be referred to tolerance improves measurably and evident. Inadequate response warrants generally should achieve tolerance of a specialist for urgent evaluation. perceptively. Continue, emphasize self-care. consideration for evaluation by foot and weight bearing and normal walking. • Uncertain mechanical etiology, severe • Limited improvement: Conditions likely to ankle specialist. • Good improvement: Most acute pain/restriction: rule out fracture and respond slower include Grade III sprains, • Good improvement: At or near pain free, mechanical foot and ankle problems dislocation; expect some early measurable Achilles tendon rupture, hallux rigidus, high nearly full function. Transition to self-care, should resolve fully. Improvement in improvement w/ combined active exercise ankle sprain. Measureable change should be periodic follow-up assessment. function should be significant and and manual work within patient tolerance. documented. • Inadequate improvement: Pain & function measurable in severe sprains. • Known mechanical etiology: expect early