The Lower ExtremitiesThe Lower ExtremitiesThe Lower Extremities

Tye J Ouzounian, MD

Tye J Ouzounian, MDDisclosure Statement

I have received nothing of value from any organization or companyVolunteer positions

COAAAOSAOFASAssistant journal editor

The Lower Extremities

This is not basic report writingThis is not basic impairment ratingAttend COA report writing courseThis is how I consider impairment ratingsKISS

The Lower Extremities

FeetHindfeetAnklesLegs

Evaluate on basis of anatomic changes, diagnostic categories, and functional changes

KneesHipsPelvis

Impairment Evaluation Methods

Not mutually exclusiveFunctional methods when documented

Permanent Impairment

Anatomic loss:Damage to the organ system or body structureCommon in musculoskeletal sections

Functional loss:Change in function for the organ system or body structureImportant for ADL (work)

The Lower Extremities

What is the problemLower extremity impairment undervalues work disability

Impairment Rating

Impairment ratings are not intended for use as a direct determinant of work disability30% impairment / 30% reduction in work capacityGreater effect on laborer than sedentary workerImpairment rating does not measure work disability

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The Lower Extremities

Guides has many inconsistenciesIf more than one method can be used, the method that provides the higher rating should be adopted

AMA Guides 5th Edition

Required to use GuidesFour corners of the Guides

AMA Guides 5th Edition

Required to use GuidesFour corners of the GuidesMy book has three dimensionsMy book has eight cornersLook deeper into the bookUse Guides to provide highest rating

The Lower Extremities

“Calculating the whole person impairment by combining the lower extremity impairments and multiplying by 0.4 should be the same as converting each lower extremity impairment to whole person impairment and then combining the whole person impairments. In cases where they are not equal, the evaluator should use the higher value”Page 560

The Lower Extremities

Lower extremity impairmentLE impairment x 0.4 = whole person

Whole person impairment

The Lower Extremities

AnatomyDiagnosis based estimatesFunction: More important clinically and often rates higher

GaitRange of motionMuscle strength

Chapter 17 tables

Incorporate into reportDocument injured worker’s findingsShow them your work

Cross Usage Chart

Limb length discrepancyGait derangementAtrophyMuscle strengthRange of motion / ankylosisArthritis

AmputationDiagnosis Based estimatesSkin lossNerve injuryCRPSVascular

Cross Usage Chart

Explain why method chosenChose method that is most clinically accurateCombine methods with combined values chartChose method that give highest impairment rating

Combined Values Chart

Lower ExtremityImpairment

Separate methods on same regionCombine regional impairmentsThen convert to whole person impairment ratingI work in whole person impairment

Lower Extremity Impairment

Lower extremity impairment x 0.4 = Whole person impairmentEvaluate each area separatelyConvert to whole personCombine using combined values chart

GaitDerangement

Always a secondary conditionSupport with pathologic findingsDo not combine with other methodsDo not use if subjective symptoms onlyAssistive device requiredExample 17.2

Station, Gait and Movement Disorders

Impairment determined by effect on ambulation Use for complex regional pain syndrome

Joint Ankylosis

Joint Whole Person %Hip 20

Knee 27Ankle 4

Pantalar 10

Diagnosis Based Estimates17.2j

Diagnosis Based EstimatesTHR / TKR

For hip and knee replacement, rate first with table 17-34 or 17-35Apply table 17-33

Good result: 15% whole personPoor result: 30% whole person

If both THR and TKR combine impairments with combined values chart

Trimalleolar Ankle Fracture

54 y/o female: 9 months s/p ORIF.Joint space preservedMotion 50% of normal1.5 cm calf atrophyAble to stand and walk 4 hours dayUses cane full time when out of house

Trimalleolar Ankle Fracture

Option 1: DBE = 8% wpOption 2: Atrophy = 2% wpOption 3: Range motion = 3% wp

Trimalleolar Ankle Fracture

Option 1: DBE: 8% wpOption 2: Atrophy: 2% wpOption 3: Range motion: 3% wpOption 4: Gait: 20% wp

Calcaneus Fracture

39 y/o Hispanic roofer: 12 months s/p ORIF

Hindfoot neutralNo hindfoot motionAnkle motion 50% of normal2 cm calf atrophySubtalar joint space 0 mmTibia-Os calcis angle 115 degreesCannot return to work

Calcaneus Fracture

Option 1: Atrophy: 3% wpOption 2: Range motion: 3% wp + ankylosis: 4% = 7% wp

Calcaneus Fracture

Option 1: Atrophy: 3% wpOption 2: Range motion: 3% wp, ankylosis: 4% = 7% wpOption 3: DBE: 6% wp + arthritis: 10% = 15% wp

Calcaneus Fracture

Option 3: DBE: 6% wp + arthritis: 10% = 15% wpOption 4:

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