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## Complete Summary

#### GUIDELINE TITLE

Ankle & foot (acute & chronic).

#### BIBLIOGRAPHIC SOURCE(S)

Work Loss Data Institute. Ankle & foot (acute & chronic). Corpus Christi
(TX): Work Loss Data Institute; 2008. 152 p. \[185 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Work Loss Data Institute.
Ankle & foot (acute & chronic). Corpus Christi (TX): Work Loss Data
Institute; 2007 Jul 3. 146 p.

The *Official Disability Guidelines* product line, including *ODG
Treatment in Workers Comp*, is updated annually, as it has been since
the first release in 1996.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Work-related ankle and foot disorders

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Emergency Medicine\
Family Practice\
Internal Medicine\
Orthopedic Surgery\
Podiatry

#### INTENDED USERS

Advanced Practice Nurses\
Health Care Providers\
Health Plans\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To offer evidence-based step-by-step decision protocols for the
assessment and treatment of workers\' compensation conditions

#### TARGET POPULATION

Workers with occupational disorders of the ankle and foot

#### INTERVENTIONS AND PRACTICES CONSIDERED

The following interventions/procedures were considered and recommended
as indicated in the original guideline document:

1.  Achilles tendon ruptures (treatment)

2.  Ankle support (lace-up and semi-rigid)

3.  Ankle foot orthosis (AFO) for foot drop

4.  Anterior drawer test

5.  Anti-inflammatory medications (NSAIDS) and acetaminophen

6.  Bed rest (Not recommended beyond 24 hours)

7.  Bone-growth stimulators or ultrasound fracture healing (as an option
    for non-union of long bone fractures)

8.  Bracing (immobilization) for clearly unstable joint

9.  Cast (immobilization) for clearly unstable joint

10. Causality (determination)

11. Cold packs/ice packs

12. Early mobilization, functional treatment, and partial weight bearing
    as tolerated

13. Exercise

14. Low energy extracorporeal shock wave therapy (see original guideline
    document)

15. Functional treatment

16. Fusion (for specific indications see the original guideline
    document)

17. Hyperbaric oxygen therapy (HBOT) (as an option for diabetic skin
    ulcers)

18. Imaging/radiography including:

    -   Plain films

    -   Bone scans (*for specific indications* see original guideline
        document)

    -   Computed tomography (CT)

    -   Diagnostic ultrasound

    -   Magnetic resonance imaging (MRI) (for specific indications see
        the original guideline document)

19. Inversion stress test

20. Lymphedema pumps or vasopneumatic devices

21. Manual wheelchair

22. Mechanical treatment (taping, orthoses)

23. Night splints (dorsiflexion and tension night splint)

24. Nonprescription medications (acetaminophen, non-steroidal
    anti-inflammatory drugs \[NSAIDs\])

25. Osteotomy for hallux valgus

26. Ottawa Ankle Rules (OAR)

27. Patient education

28. Physical therapy

29. Plantar fascia stretch

30. Rest, ice, compression, & elevation (RICE)

31. Return to work

32. Stretching (flexibility)

33. Surgery for:

    -   Achilles tendon ruptures

    -   Ankle sprains

    -   Calcaneal fractures

    -   Hallux valgus

    -   Tarsal tunnel syndrome (after conservative treatment for at
        least one month)

34. Tai Chi

35. Taping

36. Therapeutic exercise

37. Thompson test (on patients with suspected injury of the Achilles
    tendon)

38. Venous thrombosis prophylaxis for patients at high-risk of
    developing venous thrombosis

39. Work restrictions/modifications

40. Wound dressings

The following interventions/procedures are under study and are not
specifically recommended:

1.  Autologous conditioned serum (ACS)

2.  Corticosteroids (topical)

3.  Early recognition and appropriate treatment of diabetic
    complications

4.  Elastic bandage (immobilization)

5.  Heat therapy (ice/heat)

6.  Heel pads

7.  Lineal tomography

8.  Orthotic devices

9.  Steroids (injection)

The following interventions/procedures were considered but are not
currently recommended:

1.  Accommodative modalities

2.  Actovegin

3.  Acupuncture

4.  Arthroplasty (total ankle replacement)

5.  Biofeedback

6.  Continuous-flow cryotherapy

7.  Diathermy

8.  Electron generating device

9.  Extracorporeal shock wave therapy (high energy)

10. Heparin

11. Immobilization

12. Ingrown toenail surgery

13. Insoles with magnetic foil

14. Iontophoresis

15. Laser therapy

16. Magnets

17. Manipulation/chiropractic

18. Massage

19. Narcotics

20. Phonophoresis

21. Power mobility devices (PMDs)

22. Prolotherapy/sclerotherapy

23. Surgery for charcot arthropathy

24. Surgery for plantar fasciitis except in severe cases

25. Transcutaneous electrical neurostimulation (TENS)

26. Therapeutic ultrasound

#### MAJOR OUTCOMES CONSIDERED

-   Sensitivity and specificity of diagnostic tests

-   Effectiveness of treatment (e.g., in relieving pain, swelling, and
    tenderness and improving joint stability)

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Work Loss Data Institute (WLDI) conducted a comprehensive medical
literature review (now ongoing) with preference given to high quality
systematic reviews, meta-analyses, and clinical trials published since
1993, plus existing nationally recognized treatment guidelines from the
leading specialty societies. WLDI primarily searched MEDLINE and the
Cochrane Library. In addition, WLDI also reviewed other relevant
treatment guidelines, including those in the National Guideline
Clearinghouse, as well as state guidelines and proprietary guidelines
maintained in the WLDI guideline library. These guidelines were also
used to suggest references or search terms that may otherwise have been
missed. In addition, WLDI also searched other databases, including MD
Consult, eMedicine, CINAHL, and conference proceedings in occupational
health (i.e., American College of Occupational and Environmental
medicine \[ACOEM\]) and disability evaluation (i.e., American Academy of
Disability Evaluating Physicians \[AADEP\], American Board of
Independent Medical Examiners \[ABIME\]). Search terms and questions
were diagnosis, treatment, symptom, sign, and/or body-part driven,
generated based on new or previously indexed existing evidence,
treatment parameters and experience.

In searching the medical literature, answers to the following questions
were sought: (1) If the diagnostic criteria for a given condition have
changed since 1993, what are the new diagnostic criteria? (2) What
occupational exposures or activities are associated causally with the
condition? (3) What are the most effective methods and approaches for
the early identification and diagnosis of the condition? (4) What
historical information, clinical examination findings or ancillary test
results (such as laboratory or x-ray studies) are of value in
determining whether a condition was caused by the patient\'s employment?
(5) What are the most effective methods and approaches for treating the
condition? (6) What are the specific indications, if any, for surgery as
a means of treating the condition? (7) What are the relative benefits
and harms of the various surgical and non-surgical interventions that
may be used to treat the condition? (8) What is the relationship, if
any, between a patient\'s age, gender, socioeconomic status and/or
racial or ethnic grouping and specific treatment outcomes for the
condition? (9) What instruments or techniques, if any, accurately assess
functional limitations in an individual with the condition? (10) What is
the natural history of the disorder? (11) Prior to treatment, what are
the typical functional limitations for an individual with the condition?
(12) Following treatment, what are the typical functional limitations
for an individual with the condition? (13) Following treatment, what are
the most cost-effective methods for preventing the recurrence of signs
or symptoms of the condition, and how does this vary depending upon
patient-specific matters such as underlying health problems?

More information about the selection of evidence is available in
\"Appendix. ODG Treatment in Workers\' Comp. Methodology description
using the AGREE instrument\" (see \"Availability of Companion
Documents\" field).

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Ranking by Type of Evidence**

1.  Systematic Review/Meta-Analysis

2.  Controlled Trial-Randomized (RCT) or Controlled

3.  Cohort Study-Prospective or Retrospective

4.  Case Control Series

5.  Unstructured Review

6.  Nationally Recognized Treatment Guideline (from
    [www.guideline.gov](http://www.guideline.gov/))

7.  State Treatment Guideline

8.  Other Treatment Guideline

9.  Textbook

10. Conference Proceedings/Presentation Slides

**Ranking by Quality within Type of Evidence**

a.  High Quality

b.  Medium Quality

c.  Low Quality

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

The Work Loss Data Institute (WLDI) reviewed each article that was
relevant to answering the question at issue, with priority given to
those that met the following criteria: (1) The article was written in
the English language, and the article had any of the following
attributes: (2) It was a systematic review of the relevant medical
literature, or (3) The article reported a controlled trial -- randomized
or controlled, or (4) The article reported a cohort study, whether
prospective or retrospective, or (5) The article reported a case control
series involving at least 10 subjects, in which the assessment of
outcome was determined by a person or entity independent from the
persons or institution that performed the intervention the outcome of
which is being assessed.

Especially when articles on a specific topic that met the above criteria
were limited in number and quality, WLDI also reviewed other articles
that did not meet the above criteria, but all evidence was ranked using
the methodology described above, (see the Rating Scheme of the Strength
of Evidence field) so that the quality of evidence could be clearly
determined when making decisions about what to recommend in the
Guidelines. Articles with a Ranking by Type of Evidence of Case Reports
and Case Series were not used in the evidence base for the Guidelines.
These articles were not included because of their low quality (i.e.,
they tend to be anecdotal descriptions of what happened with no attempt
to control for variables that might affect outcome). Not all the
evidence provided by WLDI was eventually listed in the bibliography of
the published Guidelines. Only the higher quality references were
listed. The criteria for inclusion was a final ranking of 1a to 4b (the
original inclusion criteria suggested the methodology subgroup), or if
the Ranking by Type of Evidence was 5 to 10, the quality ranking should
be an \"a.\"

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

The guideline developers reviewed published cost analysis.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Prior to publication, select organizations and individuals making up a
cross-section of medical specialties and typical end-users externally
reviewed the guideline.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**[Initial Evaluation and Presumptive Diagnosis of Ankle
Injuries]{.underline}**

The injury should be classified into a presumptive diagnosis, which will
dictate the path of care. After a complete, definitive evaluation is
finished, the injury may, in some cases, need to be reclassified.
Subsequent to a thorough evaluation, the diagnosis may change (e.g., if
the physician classifies a patient with a sprain and the x-rays
subsequently show a fracture).

**Initial Evaluation**

1.  Ascertain the type of trauma (inversion/eversion or
    dorsiflexion/plantar flexion).

2.  Determine whether the problem is acute, subacute, chronic, or of
    insidious onset.

3.  Determine the severity and specific anatomic location of the pain.

4.  Assess the ability of the patient to bear weight, from no to full
    weight-bearing ability.

5.  Search for any evidence of an open or penetrating wound.

6.  Search for any evidence of deformity (anterior/posterior or
    lateral/medial).

7.  Test the range-of-motion of the joint.

8.  Document any present medication.

9.  Document any history of systemic disease or previous ankle injury or
    disability.

**Presumptive Diagnosis** (See the original guideline document for
International Classification of Diseases, Ninth Revision \[ICD-9\]
codes)

-   Fracture or dislocation

-   Sprain, sprain-fracture, or contusion

-   Laceration

-   Achilles tendonitis

-   Other diagnoses

    -   Plantar fasciitis

    -   Calcaneal spur

    -   Hallux valgus

    -   Tarsal tunnel syndrome

    -   Traumatic arthritis, acute episode

    -   Systemic disease (e.g., gout, rheumatoid arthritis \[RA\],
        psoriasis)

**[Fracture or Dislocation]{.underline}**

A.  **Definitive Evaluation**

    -   Record a history of the cause of the injury.

    -   Search for any evidence of an open wound in the vicinity of the
        fracture.

    -   Perform a clinical examination for deformity, tenderness, or
        ecchymosis or associated nerve, neurovascular, or tendon injury.

    -   Evaluate for evidence of joint instability.

    -   Search for any evidence of dislocation or arterial vascular
        compromise (cold, dusky foot with loss of sensation), pulse, and
        possibly sensation. If found, an immediate reduction should take
        place (prior to x-rays if necessary).

    -   Perform an evaluation for an associated injury of the foot.

    -   X-ray the ankle (two views). Special views such as mortise
        should be obtained when necessary (Refer to the Ottawa Ankle
        Rules in the original guideline document \[Stiell et al.,
        1994\]).

    -   For detailed imaging criteria, see (in the original guideline
        document)

        -   Indications for imaging \-- Plain films (Radiography,
            anterior-posterior \[AP\], lateral, etc.)

        -   Indications for imaging \-- MRI (Magnetic resonance imaging)

        -   Indications for imaging \-- Bone Scan (Radioisotope Bone
            Scanning)

        -   Indications for imaging \-- Ultrasound

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B.  **Initial Therapy**

    -   Simple, undisplaced stable fractures with no component of the
        fracture at the level of the ankle mortise (the gliding joint
        between the distal ends of the tibia and fibula and the proximal
        end of the talus) can be treated by the primary care physician.

        -   A trilateral splint should be applied initially for two to
            three weeks. The patient will need crutches and should avoid
            weight bearing. Swelling is controlled with constant
            elevation above the heart.

        -   Ice and elevation for 24 to 48 hours is appropriate.

        -   Post-fracture, two to three weeks (after the swelling has
            subsided), it is appropriate to apply a fiberglass cast with
            the foot at 90 degrees. This allows the addition of a shoe
            for conversion to a walking cast one to three weeks after
            the cast has been applied. When casting, consider checking
            for vasomotor and sensory compromise. Weight-bearing is
            progressed to 50% with crutches until six weeks post-injury,
            when full weight-bearing is allowed and crutches are
            discontinued.

        -   Analgesics for up to two weeks are appropriate, but in
            treating fractures, nonsteroidal anti-inflammatory drugs
            (NSAIDS) may be associated with side effects that are
            deleterious to treatment outcome, including delayed bone
            healing. Pain is usually due to swelling and is best
            controlled with elevation of the ankle and foot. An initial
            intramuscular (IM) pain injection is often indicated.

        -   The patient should be rechecked seven to ten days after the
            fracture, seven to ten days after beginning partial
            weight-bearing, and after progressing to full
            weight-bearing.

        -   X-rays are repeated during the above visits and after the
            cast is removed at six weeks.

        -   Physical therapy (one to five visits) to teach patient
            range-of-motion and muscle-strengthening exercises may be
            needed after cast removal.

        -   If using a removable cast, starting at four weeks the
            patient should be allowed to begin gentle range-of-motion
            exercises with the cast off.

        -   Prescribe level of activity at work and job modifications at
            each visit.

    -   Nondisplaced, bimalleolar fractures should be referred to an
        orthopedic surgeon, as they are potentially unstable.

    -   All other ankle fractures should be referred to an orthopedic
        surgeon. Compound fractures, when appropriate, should have a
        tetanus toxoid injection before being referred to an orthopedic
        surgeon.

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C.  **Secondary Evaluation for Patients with Persistent Symptoms or
    Minimal Improvement after Six Weeks of Therapy**

    -   Review for compliance of the employee and employer to therapy
        programs and job modifications and restrictions. Also review for
        insurance company cooperation.

    -   Evaluate for delayed union, malalignment, or signs of associated
        tendon or nerve injury or signs of reflex sympathetic dystrophy
        (complex regional pain syndrome \[CRPS 1\]).

    -   Promptly refer to an orthopedic surgeon if one of these
        conditions is found, otherwise continue therapy.

    -   Refer to specialist needs to be considered before six weeks for
        conditions like compartment syndrome.

+-----------------------------------------------------------------------+
| **Official Disability Guidelines (ODG) Return-To-Work Pathways**      |
|                                                                       |
| Closed reduction, sedentary/modified work: 1 to 7 days                |
|                                                                       |
| Closed reduction, standing work without cast: 42 days                 |
|                                                                       |
| Open reduction, internal fixation, sedentary/modified work: 14 days   |
|                                                                       |
| Open reduction, internal fixation, standing work without cast: 84     |
| days                                                                  |
|                                                                       |
| Comorbidity fracture blister, add: 21 days                            |
|                                                                       |
| (See *ODG Capabilities & Activity Modifications for Restricted Work*  |
| under \"Work\" in the Procedure Summary of the original guideline     |
| document)                                                             |
+-----------------------------------------------------------------------+

D.  **Other Considerations**

    -   Posterior fracture dislocation of the ankle is a serious injury
        and is frequently associated with neurovascular compression and
        with a cyanotic, cold foot. It is sometimes prudent to
        immediately reduce the dislocation, even prior to obtaining
        x-rays. \"Pure\" dislocations of the ankle are rare.

    -   Trimalleolar fractures and Pott\'s fractures (fractures of the
        distal fibula with torn deltoid ligament) are more commonly
        associated with this injury.

    -   An open wound in the vicinity of a fracture makes it a compound
        fracture, even if no clear connection to the fracture site is
        apparent. All compound fractures should be referred to an
        orthopedic surgeon immediately for care.

    -   Neurovascular injuries are a consideration in any fracture,
        particularly in the ankle, knee, wrist, and elbow. In the ankle,
        the common injured structures include the posterior tibial
        artery (which wraps around the posterior-inferior border of the
        medial malleolus) and the sural nerve (distal to the lateral
        malleolus). Therefore, it is important to evaluate the foot
        distal to the fracture to determine if there is evidence of
        nerve or vascular damage. The sural nerve is sensory and
        supplies the lateral foot. Vascular injury is detected by
        cyanosis and coldness of the foot. Since pulses are often
        difficult to palpate in a swollen ankle, a Doppler examination
        should be employed if a pulse is not felt. Vascular competence
        is further checked by comparing the circulatory return of a
        blanched nailbed to the contralateral side.

    -   Compartment syndrome (CS) is a limb-threatening and
        life-threatening condition observed when perfusion pressure
        falls below tissue pressure in a closed anatomic space. The
        current body of knowledge unequivocally reflects that untreated
        CS leads to tissue necrosis, permanent functional impairment,
        and, if severe, renal failure and death. Need referral to
        ortho/trauma surgeon to check pressures and consider fasciotomy.

    -   The standard anteroposterior and lateral ankle x-ray
        occasionally needs to be enhanced by special views. For example,
        a mortise view detects small but significant widening of the
        ankle mortise that requires surgical repair for torn ligaments.

    -   Undisplaced ankle fractures, except those having a component of
        the fracture at the level of the ankle mortise, can be treated
        by the primary care physician. If the fracture line of the tibia
        or fibula is adjacent to the level of the mortise, it is prudent
        to refer the patient to an orthopedic surgeon. Although these
        fractures may initially appear stable, they are unstable and
        prone to displace within a few days. Generally, they are treated
        surgically.

    -   A trilateral splint is used for the initial splinting of stable
        fractures of the ankle until the swelling subsides. The splint
        is then replaced by one of several types of casts (below the
        knee nonweight-bearing cast, walking cast, or removable cast
        boot). The splint is applied in the following manner: With the
        patient in the prone position, the knee flexed to 90 degree
        angle, with an assistant or family member supporting the ankle
        in the neutral position by the great toe, a four-inch Webril or
        case padding is wrapped from the base of the toes to the tibial
        tubercle. Next, five layers of 5 x 30 inch plaster are applied,
        starting at the back of the upper calf and passing over the heel
        to the base of the toes, doubling back and are smoothed. Then
        five layers of a 5 x 30 inch plaster are applied laterally,
        beginning high on the calf, passing over the lateral malleolus,
        under the plantar aspect of the foot, and up the medial side as
        far as possible. This is held in place by an Ace or Coban
        bandage. A Coban bandage has less give than an Ace bandage and
        should be applied with just one overlapping layer to avoid
        excess compression.

    -   See Criteria for Fusion (ankle, tarsal, metatarsal) in the
        original guideline document to treat non- or malunion of a
        fracture, or traumatic arthritis secondary to on-the-job injury
        to the affected joint.

**[Sprain, Sprain-fracture, or Contusion]{.underline}**

+-----------------------------------------------------------------------+
| **ODG Return-To-Work Pathways**                                       |
|                                                                       |
| Ankle strapping/soft cast, mild sprain (Grade I)\*: 1 day             |
|                                                                       |
| Ankle strapping/soft cast, severe sprain (Grade II-III)\*,            |
| sedentary/modified work (10 days crutches): 4 to 5 days               |
|                                                                       |
| Ankle strapping/soft cast, severe sprain, manual/standing work: 21    |
| days                                                                  |
|                                                                       |
| Achilles tendon repair, sedentary/modified work: 10 days              |
|                                                                       |
| Achilles tendon repair, manual/standing work, without cast: 49 to 63  |
| days                                                                  |
+-----------------------------------------------------------------------+

**\*Definition of Sprain/Strain Severity Grade**: In general, a **Grade
I** or mild sprain/strain is caused by overstretching or slight tearing
of the ligament/muscle/tendon with no instability, and a person with a
mild sprain usually experiences minimal pain, swelling, and little or no
loss of functional ability. Although the injured muscle is tender and
painful, it has normal strength. A **Grade II** sprain/strain is caused
by incomplete tearing of the ligament/muscle/tendon and is characterized
by bruising, moderate pain, and swelling, and a **Grade III**
sprain/strain means complete tear or rupture of a
ligament/muscle/tendon. A sprain is a stretch and/or tear of a ligament
(a band of fibrous tissue that connects two or more bones at a joint). A
strain is an injury to either a muscle or a tendon (fibrous cords of
tissue that connect muscle to bone). (Hannafin, Kitaoka & Panagis,
2004).

-   A definitive evaluation of a sprain is important, as sprains are the
    most common injury of the ankle, and inversion sprains make up the
    majority. Eversion sprains may be more severe due to their
    association with syndesmosis injuries. One classification of sprains
    is Grades I, II, and III\* (least serious to most serious), and it
    is helpful to classify sprains in this manner as a guide to the
    initial therapy and prognosis. (Ankle sprains can range from
    stretching \[grade 1\] to partial rupture \[grade 2\] to complete
    rupture of the ligament \[grade 3\] \[Litt, 1992\]). Evaluations for
    a sprained ankle include: check for the area of maximal tenderness;
    on the lateral side examine the anterior talofibular ligament, the
    calcaneofibular ligament, and posterial talofibular ligament; check
    the syndesmosis area; examine the mid-tarsal joint; check for
    injuries to the posterior tibial and peroneal tendons; examine for
    possible fracture of the base of the fifth metatarsal, anterior
    process of the calcaneus, osteochondral lesion of the talus, lateral
    process of the talus; and check for tenderness of the medial and
    lateral malleoli.

-   A sprain-fracture refers to the small flakes of bone avulsed from
    the calcaneus or talus in sprains of the ankle. These flakes
    represent small avulsions of bone attached to the injured
    calcaneofibular ligament or the talofibular ligament.
    Sprain-fractures are treated in the same manner as the grade of
    sprain they represent and can be treated by the primary care
    physician unless they are clinically a Grade III.\*

-   Peroneal tendon injuries are associated with Grades II and III ankle
    sprains of the inversion type. Peroneal tendons (longus and brevis)
    traverse distal to the lateral malleolus, and their retaining
    retinacula are sometimes torn with sprains of the ankle. Examination
    includes dorsiflexion/eversion of the foot and having the patient
    resist passive inversion. This forces the injured tendon to ride up
    over the lateral malleolus. Treatment is a short leg cast with ankle
    in 30 degree plantar flexion for six weeks.

-   Traction injuries to the peroneal and sural nerves can occur with
    sprains of the ankle. They are detected by careful palpation of the
    nerves for tenderness. The sural nerve runs posterior and distal to
    the lateral malleolus. Injury to these nerves may occasionally lead
    to reflex sympathetic dystrophy. The Ottawa rules, developed by
    Stiell et al., identify those cases of ankle sprain that need
    x-rays. Fractures commonly associated with ankle sprains include the
    following:

    -   Talus (lateral process) fracture

    -   Osteochondral fractures of the dome of the talus (may require
        magnetic resonance imaging \[MRI\] or bone scan of the
        tibial-talar joint for diagnosis)

    -   Calcaneus-anterior process fractures

    -   Fracture of base or shaft of fifth metatarsal

-   Stress x-rays may be indicated in acute sprains, but they are more
    commonly used in unstable chronic sprains to delineate the degree of
    ligamentous laxity present. Stress x-rays are usually performed by a
    radiologist or an orthopedic surgeon.

-   Syndesmosis refers to joints, such as the tibiofibular joint, held
    by ligaments without articular surfaces. The syndesmosis of the
    ankle is the tibiofibular ligament between the distal fibula and the
    tibia. Disruption of the tibiofibular ligament will demonstrate
    tenderness over that area and can be detected by a positive
    \"squeeze test\" and a special x-ray view of the ankle with the
    tibia held firmly and the foot rotated externally (which may show
    widening of the ankle mortise). This injury is often a surgical
    problem and should be referred to an orthopedic surgeon for
    treatment.

-   The squeeze test is accomplished by grasping the tibia in the palm
    of one hand and the fibula in the other and squeezing them together
    in the lower third. Pain in the area just above the ankle mortise on
    the lateral side is a sign of syndesmosis injuries.

-   The anterior drawer test is for abnormal anterior/posterior motion
    of the ankle following a sprain. It is performed by firmly applying
    pressure on the anterior distal tibia and grasping the os calcis
    posteriorly and pulling anteriorly. Excess motion when compared with
    the contralateral side is judged a positive test or positive
    \"anterior drawer sign.\"

-   Inversion instability is tested by holding the distal end of the
    tibia and fibula firmly. The calcaneus is grasped with the other
    hand into maximum inversion and eversion. Comparison is made with
    the contralateral side. See \"Inversion stress test\" in the
    original guideline document.

-   Sprains that are not responding to therapy are often an indication
    to x-ray or repeat x-ray to check for fractures not previously
    detected, such as osteochondral fractures of the talus.

-   Approximately 10% to 20% of all sprains will either fail
    conservative management or will be severe enough to require
    orthopedic evaluation. A review of 12 studies comparing surgery with
    functional treatment shows that controlled movement is the treatment
    of choice for lateral ligament injuries of the ankle. Patients who
    had failed conservative therapy and delayed surgical repair had as
    good results from the surgery as patients who had primary surgery.
    Possible contraindications to nonsurgical management of ankle
    sprains that require orthopedic referral include the following:

    -   Associated displaced osteochondral fracture

    -   Displaced anterior tibial lip fracture

    -   Chronic instability

    -   Combined medial and lateral ligamentous injuries

**[Laceration]{.underline}**

+-----------------------------------------------------------------------+
| **ODG Return-To-Work Pathways**                                       |
|                                                                       |
| Minor: 0 days                                                         |
|                                                                       |
| Major, clerical/modified work: 3 days                                 |
|                                                                       |
| Major, manual work: 8 days                                            |
|                                                                       |
| Major, heavy manual work: 14 days                                     |
|                                                                       |
| Tendon repair, clerical/modified work: 14 days                        |
|                                                                       |
| Tendon repair, manual work: 91 days                                   |
+-----------------------------------------------------------------------+

-   A laceration produced by crush injury needs an x-ray to rule out any
    underlying fracture and to answer any question of penetration of the
    joint or a foreign body in the wound.

-   Neurovascular and tendon function need evaluation with any
    laceration around a joint. No anesthesia should be used in the wound
    until the sensation has been checked distal to the laceration and
    the function of the tendons has been identified as intact.

-   Antibiotic therapy for contaminated lacerations should include both
    anti-staphylococcal and broad-spectrum coverage.

-   Need to check for foreign body, clean/irrigate wound, evaluate
    tetanus risk, and provide instruction on suture care/schedule for
    removal, as needed.

**[Achilles Tendonitis]{.underline}**

+-----------------------------------------------------------------------+
| **ODG Return-To-Work Pathways**                                       |
|                                                                       |
| Without surgery, clerical/modified work: 0 days                       |
|                                                                       |
| Without surgery, manual/standing work: 5 to 7 days                    |
|                                                                       |
| With surgery, clerical/modified work: 7 to 10 days                    |
|                                                                       |
| With surgery, manual/standing work: 42 to 49 days                     |
+-----------------------------------------------------------------------+

-   The Thompson test (also called the Thomas test) is used to diagnose
    Achilles tendon rupture. Squeeze the calf with the patient in a
    prone position and with the foot off the examining table. With an
    intact tendon, the foot will plantar flex. This is a very accurate
    test.

-   Laboratory studies are usually not necessary. However, with
    persistent symptoms, an arthritis panel and a serum uric acid test
    may be necessary.

-   Achilles tendonitis requires initial therapy of an Achilles
    stretching program. The latter can be implemented by a single visit
    to a physical therapist or may be taught by the physician.
    Additionally, a heel lift in the shoe may be of value. Short-term
    immobilization and even non-weight-bearing are also commonly needed.
    Because there is an association with late rupture of the tendon,
    most physicians suggest it is inappropriate to inject steroids into
    the bursa or the tendon sheath.

-   An x-ray of the ankle is appropriate to rule out other pathology
    including bone pathology in the presence of persistent tendonitis
    with little improvement. Noncompliance by the patient with the
    stretching program is frequently implicated with slow improvement of
    symptoms.

-   Achilles tendonitis patients who have no improvement after 30 days
    of therapy need an orthopedic consultation to assist in defining
    appropriate therapy and to rule out complicating factors.

-   Patient noncompliance is the cause of failure to improve in up to
    90% of cases. The majority of the remaining cases are related to
    unrecognized associated pathology such as osteochondral fractures in
    ankle injuries.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=12657)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

During the comprehensive medical literature review, preference was given
to high quality systematic reviews, meta-analyses, and clinical trials
over the past ten years, plus existing nationally recognized treatment
guidelines from the leading specialty societies.

The heart of each Work Loss Data Institute guideline is the Procedure
Summary (see the original guideline document or the National Guideline
Clearinghouse summary list provided in the \"Interventions and Practices
Considered\" field), which provides a concise synopsis of effectiveness,
if any, of each treatment method based on existing medical evidence.
Each summary and subsequent recommendation is hyper-linked into the
studies on which they are based, in abstract form, which have been
ranked, highlighted, and indexed.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

These guidelines unite evidence-based protocols for medical treatment
with normative expectations for disability duration. They also bridge
the interests of the many professional groups involved in diagnosing and
treating disorders of the ankle and foot.

#### POTENTIAL HARMS

-   Open operative treatment of acute Achilles tendon ruptures compared
    with non-operative treatment is associated with a lower risk of
    rerupture, but a higher risk of other complications including
    infection, adhesions and disturbed skin sensibility

-   Non-steroidal anti-inflammatory drugs (NSAIDs) may be associated
    with side effects that are deleterious to treatment outcome,
    including delayed bone healing.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Possible contraindications to nonsurgical management of ankle
    sprains that require orthopedic referral include the following:

    -   Associated displaced osteochondral fracture

    -   Displaced anterior tibial lip fracture

    -   Chronic instability

    -   Combined medial and lateral ligamentous injuries

-   Extracorporeal shock wave therapy (ESWT) is contraindicated in
    pregnant women; patients younger than 18 years of age; patients with
    blood clotting diseases, infections, tumors, cervical compression,
    arthritis of the spine or arm, or nerve damage; patients with
    cardiac pacemakers; patients who had physical or occupational
    therapy within the past 4 weeks; patients who received a local
    steroid injection within the past 6 weeks; patients with bilateral
    pain; patients who had previous surgery for the condition.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The Treatment Planning sections outline the most common pathways to
recovery, but there is no single approach that is right for every
patient and these protocols do not mention every treatment that may be
recommended. See the Procedure Summaries (in the original guideline
documents and in the National Guideline Clearinghouse\'s \"Interventions
and Practices Considered\' fields) for complete lists of the various
options that may be available, along with links to the medical evidence.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Patient Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Work Loss Data Institute. Ankle & foot (acute & chronic). Corpus Christi
(TX): Work Loss Data Institute; 2008. 152 p. \[185 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 (revised 2008 Apr 15)

#### GUIDELINE DEVELOPER(S)

Work Loss Data Institute - Public For Profit Organization

#### SOURCE(S) OF FUNDING

Not stated

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Editor-in-Chief, Philip L. Denniston, Jr. and Senior Medical Editor,
Charles W. Kennedy, Jr., MD, together pilot the group of approximately
80 members. See the ODG *Treatment in Workers Comp* [Editorial Advisory
Board](http://www.odg-disability.com/editorial_advisory_board.htm).

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

There are no conflicts of interest among the guideline development group
members.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Work Loss Data Institute.
Ankle & foot (acute & chronic). Corpus Christi (TX): Work Loss Data
Institute; 2007 Jul 3. 146 p.

The *Official Disability Guidelines* product line, including *ODG
Treatment in Workers Comp*, is updated annually, as it has been since
the first release in 1996.

#### GUIDELINE AVAILABILITY

Electronic copies: Available to subscribers from the [Work Loss Data
Institute Web site](http://www.odg-disability.com/).

Print copies: Available from the Work Loss Data Institute, 169 Saxony
Road, Suite 210, Encinitas, CA 92024; Phone: 800-488-5548, 760-753-9992,
Fax: 760-753-9995; [www.worklossdata.com](http://www.worklossdata.com/).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Background information on the development of the Official Disability
    Guidelines (ODG) of the Work Loss Data Institute is available from
    the [Work Loss Data Institute Web
    site](http://www.odg-disability.com/odgtwclist.htm).

-   Appendix A. ODG Treatment in Workers\' Comp. Methodology description
    using the AGREE instrument. Available to subscribers from the [Work
    Loss Data Institute Web
    site](http://www.odg-disability.com/ODG_AGREE.htm).

#### PATIENT RESOURCES

The following is available:

-   Appendix C. Official Disability Guidelines (ODG) Treatment in
    Workers\' Comp. Patient information resources. 2008.

Electronic copies: Available to subscribers from the [Work Loss Data
Institute Web site](http://www.odg-disability.com/).

Print copies: Available from the Work Loss Data Institute, 169 Saxony
Road, Suite 210, Encinitas, CA 92024; Phone: 800-488-5548, 760-753-9992,
Fax: 760-753-9995; [www.worklossdata.com](http://www.worklossdata.com/).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This summary was completed by ECRI on February 2, 2004. The information
was verified by the guideline developer on February 13, 2004. This NGC
summary was updated by ECRI on March 24, 2005, January 3, 2006, April
10, 2006, November 8, 2006, March 27, 2007, and August 15, 2007. This
summary was updated by ECRI Institute on November 19, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
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Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
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Readers with questions regarding guideline content are directed to
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© 1998-2008 National Guideline Clearinghouse

Date Modified: 12/15/2008