joshua m. alpert, md midwest bone and joint …...-cartilage -muscle/tendon -bone optimization of...

Joshua M. Alpert, MD Midwest Bone and Joint Institute

Accelerated 2015 Worker’s Compensation “Webinar Wednesdays”

April 1st, 2015

Management of soft tissue injuries Low-energy joint trauma Acute injury Overuse injury -ligament -cartilage -muscle/tendon -bone

Optimization of function Emphasis on early post-op rehabilitation

Definitions Knee Anatomy Specific Knee Injuries

Anterior Knee Pain Patellar and Tibial Plateau Fractures Meniscus Injury ACL tears

Discussion on Impairment Ratings Question and Answer Session

Joint: where the end of 2 bones meet Lined with cartilage : acts as a load bearing and

shock absorbing frictionless surface

Tendon muscle to bone Ligament bone to bone Sprain ligament injury Strain muscle injury Laxity joint translation Subluxation pathologic laxity Dislocation no contact jnt surfaces

Ligament : Connects one bone to another limits abnormal motion between 2 bones Ex: Anterior Cruciate Ligament (ACL)

Tendon : Connects Muscle to Bone Quadriceps Tendon Achilles Tendon

Strain = pull of a muscle or tendon Tendon connects the muscle to

bone

Common Complaints: pain in muscle/did not warm up tenderness, swelling, defect ‘hollow’ possible to tear the muscle inability to contract muscle = more

severe injury

Injury to a ligament; connects bone to bone Ligaments stabilize a joint; severe sprain = a tear

Common Complaints: twisting injury, ‘pop’ heard joint slipped out of place swelling, discoloration, deformity Tenderness Decreased Range of Motion

Contusion : Bruise Common Complaint: direct blow or contact swelling or discoloration area of tenderness Difficulty in movement

Bone / Joint dislodged from normal articulation Joint no longer in proper position

P Protection R Rest I Ice C Compression E Elevation S Support

Acute - NEW

Single, traumatic event

Ex: ACL tear Ankle Sprains Hamstring Strain Fracture

Overuse Injuries More Common Subtle, occur over time Harder to diagnoses and

treat

Ex: Tennis elbow Shin splints

Anatomy Anterior Knee Pain / Patellar Pain Meniscus tears MCL tears ACL Tears

Femur/tibia/patella/ fibula ACL/PCL/MCL/LCL Meniscus Cartilage

Quadriceps tendon/ patellar

tendon

1. Onset 2. Location 3. Duration 4. Quality/Quantity 5. Aggravating Factors 6. Relieving Factors 7. Associated Symptoms 8. Effect on Function **

1. NOT Always

STRAIGHTFORWARD

Common complaint

Anterior Knee Pain = Patellofemoral Pain

Syndrome = Chondromalacia Patella

Abnormalities in the

Forces applied to the Kneecap Anatomy of the KneeCap

Usually at work from a direct blow to the front of the knee

Symptoms: Pain in the front of the knee, underneath the knee

cap (patella) Pain going up or down stairs Difficulty sitting with knees bent for a long period

of time Movie theater sign

Swelling, catching, locking

Sense of knee cap (patellar) instability Knee giving out

“Jumper’s knee” Volleyball players, basketball

players, runners Pain at the inferior pole of the

patella Repetitive microtrauma vs

macrotrauma Chronic/Nagging injury

Osgood Schlatter Disease

Association?

THE MAINSTAY OF TREATMENT FOR

PATELLOFEMORAL JOINT PROBLEMS IS REHABILITATION

Surgery indicated for patients with malalignment who have failed conservative treatment

Anti-inflammatories (Advil, Aleve) RICE (Rest, Ice, Compression, Elevation) Activity modification Taping (McConnell) Bracing Return to work full duty around 6 wks after physical therapy

Quadriceps Tendon

Patella

Patellar Retinaculum Patellar Tendon

Secondary Extensors

Illiotibial Band Medial / Lateral Patellar Retinacula

Principal function of Extensor Mechanism Maintain a standing position

Functions: when ambulating rising from a chair ascending/descending stairs …. all ways to overcome gravity

Fall from height Direct blow to the

anterior knee (dashboard injury)

Rapid knee flexion with

quadriceps resistance

Direct Injury (Comminuted Patella fx) Knee hitting the dashboard Fall onto knee Direct blow to knee

Indirect Injury (Transverse

Patella Fx) Partial fall followed by collapse

of knee Eccentric applied force to

extensor mechanism

Pain, contusions, lacerations and/or abrasions

Hemarthrosis - Swelling

Palpable defect Assessment of ability to extend the

knee against gravity

Ability to maintain the knee in full extension against gravity

� Allows prediction of treatment

Types

Transverse Marginal Vertical Stellate Comminuted Osteochondral

Indications for Surgery

Greater than 2mm articular displacement

Greater than 3mm fragment separation

Osteochondral fragment with displacement into joint

Surgical Treatment

Modified tension band wiring Cerclage Wire Patellectomy

Rehab – 6 weeks in Knee

Immobilizer or Cast Deskwork only x 6weeks PT x 3-4 months MMI at 3-4months

HX: Eccentric Injury to Knee – usually patient over 40 years old PE: Palpable Defect in tendon Unable to perform a straight leg raise. Treatment: Direct repair to bone

Rehab: Cylinder cast or Knee immobilizer Weight bearing as Tolerated Isometric exercises start around 6 weeks with straight leg raises up to 45degrees of flexion 8-10 weeks increase ROM to Full MMI at 3-4 Months

HX: Usually under 40

Y.O. Eccentric Contraction

to Knee

PE: Unable to Perform

Straight Leg raise

Treatment: Surgery Repair Tendon to

Bone

Post Op:

Hamstring and Quadriceps exercises begun immediately

Touch down weight bearing the first 2-3 weeks

At 2-3 WEEKS active flexion and passive extension

started initiated

6 weeks WBAT, resistance exercises initiated Strengthening at three months MMI 4months

20-30 y/o Women Valgus Load /

Flexed/Externally Rotated Knee

Dislocations occur at 60-70

flexion Lateral >>> Medial

Medial Patellofemoral Ligament

Spans medial epicondyle to medial patella

Also attaches to VMO and adductor tubercle

50-60% of medial restraint of the patella

Osteochondral Injury Medial Patellar Facet Lateral Condylar Ridge

Occur in up to 68% of patients

Avulsion of the Medial PatelloFemoral

Ligament

Non-Operative Treatment - 2 schools

Immobilization and Rehab 6 weeks strict Immobilization in knee Immobilizer Aggressive PT to regain motion/strenghth Recurrent instability--40-50%

Functional Treatment

Early ROM with patellar bracing Better patient scores, less instability (26%) **Most common treatment

Usually 6 week recovery to MMI

Operative Treatment: Rare Only if continue to have patellar

instability or recurrent dislocation

Acute Repair of the MPFL

(Repair of the femoral attachment)

Chronic Lateral Retinacular Release Proximal vs Distal Realignment

Rehab : 3-4 Months

History: Age and mechanism

extremely important Usually axial load

with valgus force

History: Age and mechanism extremely

important Split or wedge fractures in

younger patients with stiffer bone

Depression fractures-

older/weaker bone

Associated injuries

Ipsilateral femoral and tibial fractures

Cruciate and collateral

ligament injuries Meniscal tears 50% of plateau fractures have

meniscus

Avulsions of intercondylar eminence

Physical Exam: Integrity of the soft-tissue envelope

Blisters or abrasions Open wounds

Nerve function – peroneal nerve status Peripheral pulses Status of the compartments Other injuries Ligamentous exam- difficult

WORKUP: - XRAY - CT SCAN - ?MRI

Goals of treatment

Restore joint congruity Maintain limb alignment Allow early stable knee

motion

Non-operative treatment

Non-displaced fractures Minimally displaceed lateral plateau fractures Advanced osteoporosis Goal not anatomic reduction but restoration of axial

alignment and knee motion No more than 7 degrees malalignment No varus/valgus instability greater than 5 to 10 degrees Fractures with less than 3mm articular displacement

Absolute indication for surgery

Open plateau fractures Fractures associated with

compartment syndrome Most displaced bicondylar fractures Displaced medial condylar fractures Lateral plateau fractures with joint

instability

Non WB x 6 Weeks Rehab for ROM – 0-6 weeks WBAT at 6 weeks Strengthening at 2-3 Months MMI at 4-6 Months

Function

Load Bearing Stability

Lubrication and

nutrition Protects articular

cartilage underneath meniscus

Twisting/squatting activities Swelling develops overnight Associated with ligament injuries 20-60% Mechanical symptoms of catching, clicking,

locking common

Attempt to repair to save

meniscus function Meniscus has poor blood

supply Tear has to be in “red

zone”

Older patient New injury vs

degenerative tear over time

Treatment usually

with partial meniscectomy - Cleaning up part of meniscus that is torn

Meniscus repair: Tear in the red-red zone

Rehabilitation depends on debridement vs repair

Partial menisectomy:

Full weight bearing with PT in the first week

Full recovery around 6wks Meniscus repair

Non Wb x 6 weeks 0-90 range of motion x 6 weeks Strengthening at 3 months 3-4 months MMI

>100,000/year Females: 3-10x risk Genetic predisposition? Differences in muscle firing patterns, landing

PCL prevents tibia from moving posteriorly

ACL prevents tibia from moving anteriorly

Function: Aids in anterior knee

stability Aids in twisting,

cutting activities

Without an ACL there is a risk of meniscus and cartilage damage with recurrent instability

70%-noncontact Injured by a combination of a

sudden stop with a quick twist

Hear a ‘Pop’ Pain Rapid onset swelling Unable to play Knee feels “unstable” Do not trust knee

Lachman 1+: 1-5mm 2+: 6-10mm 3+: >10mm quality of endpoint: ‘A’- firm ‘B’- soft

ACL does not heal

Any active person with an ACL tear should consider having it reconstructed

Usually REHAB AN ACL INJURY PRIOR TO SURGERY FOR 4-6 weeks Get back full ROM Decrease swelling Improve muscle strength prior to surgery

How?

ACL cannot be repaired with stitches Need a graft (tissue to be used as a new ACL)

Graft options: Own Patellar Tendon Own Hamstring Tendons Cadaver Patellar Tendon or Hamstring Tendons

All do well, patient choice in many cases

Walk on it right away after surgery with Brace

First 6 weeks – DESKWORK ONLY Brace on at all times, including Physical Therapy. Goal :

Range of motion exercises only

6-12 weeks – DESKWORK and WALKING – NO climbing No brace, range of motion and add strengthening

exercises 3 months – start running – NO cutting or pivoting or work 4- 6 months – back to all work activity without restriction 6 mo-1 yr back to competitive sports, knee feels “normal”

The Federal Employees' Compensation Act (FECA): Does not specify the manner by which a schedule loss should be determined.

For consistency and to ensure equal justice under the law, the

American Medical Association's Guides to the Evaluation of Permanent Impairment standardized tables were made so that there may be uniform standards applicable to all claimants

The Employees' Compensation Appeals Board (ECAB) has long concurred in this adoption as a standard for evaluating schedule losses

Guides have proven a useful tool in measuring schedule impairment under FECA.

A.M.A. Guides to the Evaluation of Permanent Impairment, 6th Edition

Effective May 1, 2009, the Division of Federal Employees' Compensation (DFEC) adopted….

The American Medical Association Guides to the

Evaluation of Permanent Impairment, Sixth Edition, for schedule award entitlement determinations.

Impairment: a “loss” that reflects failure to prevent an injury or illness and/or to restore function

Impairment Rating: Goal is an accurate, unbiased assessment of impairment via efficient means – assuring valid and reliable definition

Future issues and problems are a social question not a

medical question

An Impairment rating is a number value that a physician calculates based on a patient’s: Diagnosis Functional History Physical Examination Clinical Studies (Imaging ) ** Patient must be at MMI

The number calculated = IMPAIRMENT Rating

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Physicians rate impairment based on 6th Edition AMA Guides: It is a Medical determination Medical training required Certification exam passed by the MD to perform ratings

Judges rate disability Judge “factors in” NON-medical factors

Doctors: “Do NOT think about the ability to do his/her job, availability of similar jobs in the local economy, etc., as that is the judge’s task, NOT MD’s task.”

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Example: both a lawyer and a pianist sustain an amputation of the non-dominant little finger. Both have the same impairment 100% of the digit, 10% of the hand, 9% of the upper extremity, 5%

whole person The lawyer has no disability The pianist is unable to perform his occupation Totally disabled for his occupation Fully capable of many jobs

Physician’s role: Determine IMPAIRMENT

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“In disability evaluation: the impairment rating is ONE of several determinants of disablement.

Impairment rating is the determinant most amenable to physician assessment; it must be further integrated with contextual information typically provided by nonphysician sources regarding psychological, social, vocational, and avocational issues.” – page 6

Unless otherwise specified page numbers refer to the Guides, 6th Edition

The 6th Edition AMA Guides : Provides a comprehensive, valid, reliable, unbiased, and evidence-based rating system

Has internal consistency in approach across chapters and body systems

Incorporates principles consistent with clinical care (such as the premise that treatment – including surgery – should improve function)

Has demonstrated improved inter-rater reliability

AMA Guides 6th is an independent reproducible system

Maximum Medical Improvement

Determine Diagnosis (DBI) & Class (CDX) (0-4)

Adjust Default by Net Adjustment for Grade Modifiers (GM): Functional History (FH) (0-4) Physical Examination (PE) (0-4) Clinical Studies (CS) (0-4)

Net Adjustment for each GM is GM minus CDX Move Default Impairment to left or right based on Net

Adjustment Formula (e.g. -2 net adjustment moves 2 spaces to left)

Combine Impairments if necessary

DBI: Diagnosis; going down more severe CDX: 5 Classes 0-4; left to right more severe Regional Grids

Upper Extremities (Chapter 15): Digit; Wrist; Elbow; Shoulder (CTS is UE)

Lower Extremities (Chapter 16): Foot & Ankle; Knee; Hip (Foot is UE)

Spine & Pelvis (Chapter 17): Cervical; Thoracic; Lumbar; Pelvis

Class 0: No objective problem Class 1: Mild problem Class 2: Moderate problem Class 3: Severe problem Class 4: Very severe problem

Vast majority of impairment ratings are based on diagnosis-

based impairments, with adjustments (as applicable) for function, physical examination and clinical studies

Make a diagnosis Look at the Diagnosis Grid and pick a Class (0-4)

based on the severity Use the adjustment modifiers based on the functional

history, physical exam, clinical studies After the adjustments : An Impairment rating

number for that body part is calculated from a chart Convert the impairment number to a whole body

impairment number from a chart

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Page 530-531

Determination of permanent partial disability criteria:

A physician reports impairment in writing using 6th Ed. AMA Guides.

The level of permanent partial disability is calculated using the, following factors:

the occupation, age, future earnings of the injured employee;

No single enumerated factor shall be the sole determinant of disability.

In determining the level of disability, the relevance and weight of any factors used in addition to the level of impairment as reported by the physician must be explained in a written order.

www.midwestbonejoint.com Office: 847-931-5300

dralpert@midwestbonejoint.com Cell: 773-454-1203