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