Guidelines for Treatment of the Lower Extremity

OKLAHOMA

Guidelines for Treatment of The Lower Extremity

(Knee, Ankle and Foot)

Developed and Adopted by the

Physician Advisory Committee

Adopted by the Administrator of the

Oklahoma Workers' Compensation Court

Effective September 1, 2007

2

Lower Extremity Guidelines

TABLE OF CONTENTS

INTRODUCTION .................................................................................................................................................. 4

BACKGROUND

4

DEVELOPMENT OF THE GUIDELINES

4

APPLICATION OF THE GUIDELINES

4

I.

GENERAL GUIDELINE PRINCIPLES..................................................................................................4

A.

Education

5

B.

Treatment Parameter Duration

5

C.

Active Interventions

5

D.

Active Therapeutic Exercise Program

5

E.

Positive Patient Response

5

F.

Re-evaluate Treatment Every 2-4 Weeks

5

G.

Surgical Interventions

5

H.

Six-month Time Frame

5

I.

Return to Work

6

J.

Delayed Recovery

6

II.

INITIAL DIAGNOSTIC PROCEDURES ...............................................................................................6

A.

History Taking and Physical Examination (Hx & PE)

6

1.

Knee - Significant History ...........................................................................................6

2.

Knee - History Questions.............................................................................................7

3.

Foot and Ankle - History .............................................................................................7

B.

Physical Exam

7

1.

Knee - Physical Exam..................................................................................................7

2.

Foot and Ankle - Physical Exam..................................................................................8

C.

Radiographic Imaging

8

D.

Laboratory Tests

9

E.

Inappropriate Initial Assessment Methods

9

1.

Routine arthroscopic examination ...............................................................................9

2.

MRI .............................................................................................................................9

3.

CT ................................................................................................................................ 9

III. FOLLOW-UP DIAGNOSTIC IMAGING AND TESTING PROCEDURES .........................................9

A.

Imaging Studies

9

1.

Computerized Axial Tomography and Lineal Tomography (CT)................................9

2.

Magnetic Resonance Imaging (MRI)...........................................................................9

3.

Bone Scanning .............................................................................................................9

4.

Arthrography................................................................................................................ 9

5.

Venography .................................................................................................................9

6.

Doppler Ultrasonography/Plethysmography..............................................................10

7.

Diagnostic Arthroscopy .............................................................................................10

8.

Arteriography............................................................................................................. 10

B.

Other Diagnostic Tests

10

1.

Thermography............................................................................................................ 10

2.

Compartment Pressure Measurement ........................................................................10

3.

Electro-Diagnostic Studies (Needle EMG/NCS) .......................................................10

4.

Psychometric Testing Evaluations .............................................................................10

5.

Personality/Psychological/Psychosocial Evaluations.................................................10

IV. THERAPEUTIC PROCEDURES..........................................................................................................10

A.

Non-operative Treatment:

11

1.

Initial Treatment ........................................................................................................11

2.

Immobilization........................................................................................................... 11

3.

Medication ................................................................................................................. 12

Lower Extremity Guidelines

i

4.

Therapeutic Injection .................................................................................................14

B.

Operative Treatment

14

1.

Manipulation Under Anesthesia.................................................................................14

2.

Bursectomy ................................................................................................................14

3.

Arthroscopy ...............................................................................................................14

4.

Ligament Repair or Reconstruction ...........................................................................15

5.

Arthrotomy.................................................................................................................15

6.

Osteotomy..................................................................................................................15

7.

Total Joint Replacement ............................................................................................15

8.

Fusion ........................................................................................................................15

9.

Amputation ................................................................................................................15

10. Hardware Removal ....................................................................................................15

C.

Response Criteria

15

1.

Good ..........................................................................................................................15

2.

Partial.........................................................................................................................15

3.

Poor............................................................................................................................16

V.

PHYSICAL MEDICINE AND REHABILITATION ............................................................................16

A.

Modalities

16

1.

Thermal Agents..........................................................................................................16

2.

Electrical Stimulation.................................................................................................18

3.

Vasopneumatic Devices.............................................................................................18

B.

Physical Therapy Procedures

18

1.

Iontophoresis/Phonophoresis .....................................................................................18

2.

Ultrasound..................................................................................................................18

3.

Manual Electrical Stimulation....................................................................................18

4.

Contrast Baths............................................................................................................19

5.

Hubbard Tanks...........................................................................................................19

6.

Massage .....................................................................................................................19

7.

Gait Training - Simple and Complex .........................................................................19

8.

Activities of Daily Living (ADL)...............................................................................20

9.

Therapeutic Activities................................................................................................20

10. Therapeutic Exercise..................................................................................................20

11. Neuromuscular Re-Education ....................................................................................20

12. Work Hardening Programs ........................................................................................20

13. Joint Mobilization......................................................................................................21

14. Manipulation..............................................................................................................21

15. Orthotic Training (dynamic bracing, splinting)..........................................................21

16. Prosthetic Training.....................................................................................................21

17. Myofascial Release/Soft Tissue Mobilization............................................................22

18. Manual Traction.........................................................................................................22

19. Transcutaneous Electrical Nerve Stimulation (TENS) ..............................................22

20. Hyperbaric Chamber..................................................................................................22

C.

Return to work

22

1.

In most cases..............................................................................................................22

2.

Communication..........................................................................................................23

3.

Generally....................................................................................................................23

D.

Special Tests

23

1.

Work Conditioning Assessments/Screens..................................................................23

2.

Functional Capacity Evaluation (FCE) ......................................................................23

3.

Lift Analysis...............................................................................................................23

4.

Mechanized/Computerized Strength Evaluations ......................................................23

VI. SPECIFIC JOINT INVOLVEMENT.....................................................................................................23

A.

Lower Extremity - Outlying Diagnoses

24

1.

Infections Requiring Intravenous Antibiotics ............................................................24

ii

Lower Extremity Guidelines

2.

Reflex Sympathetic Dystrophy (RSD) .......................................................................24

3.

Hardware removal .....................................................................................................24

4.

Contracture ................................................................................................................24

5.

Severe Burns, Open Wounds, Vascular Injuries, Polytrauma, and Non-union

Fractures ....................................................................................................................24

B.

Knee - Outlying Diagnoses

24

1.

Severe Intra-Articular Fracture ..................................................................................24

2.

Knee Fusion...............................................................................................................24

3.

Total Knee Replacement............................................................................................24

4.

Amputation ................................................................................................................24

5.

Meniscectomy ............................................................................................................ 24

6.

Meniscal repair ..........................................................................................................24

7.

Retropatellar Pain Syndrome .....................................................................................25

8.

Patellar Subluxation...................................................................................................25

9.

ACL/PCL Repair .......................................................................................................25

10. Automated Methods for Determining Cruciate Ligament Laxity (KT-1000, etc.).....25

11. Arthroscopy ...............................................................................................................25

12. Chondroplasties, Chondral defects and Cartilage Repairs .........................................25

C.

Foot and Ankle Injuries

25

1.

Background................................................................................................................ 25

2.

Diagnostic Criteria.....................................................................................................26

3.

Treatment ................................................................................................................... 26

Lower Extremity Guidelines

iii

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download