Hello everybody, we're going to talk about workers' compensation as the treating doctor. So you have a patient who's got some foot and ankle problems and we're going to take care of them, we're going to talk about the workers' compensation issues here and don't let it be too daunting for you, but let's talk about issues that are important for us to know about. My disclosures, none of which are relevant, but they're all listed. Welcome back to Vancouver. This is 2009, 15 years ago. Nobody ages, amazing. Had dad playing a little bit of fun and games. It was warmer back then, not as nice as it is today. Basically, some of this is going to be repeating some of the stuff that Greg brought up. Again, repetition is good. But we're going to talk about the workers' compensation system is there. We have to deal with it. And how is it going to integrate into our practice? And Greg gave me a mission to cover these basic aspects. Basically, PT, work hardening, what's an FCE? What do we care about in FCE? Return to work ideas, who the nurse case manager is, the adversarial patient, and the MMI and special cases, the option to treat. Remember, laboratory work can be dangerous. We have our own workers' comp issues in orthopedics. Who takes workers' comp? Okay, and if you have a patient, why do you want them to be your patient? I think it's important to recognize that if you have workers' compensation patients, they're going to take more of your time, and most importantly, more of your secretary's time. And if you're like me, you treasure a good secretary, you want to get them too angry. But recognize that you're going to deal with fee schedules, you're going to deal with paperwork, and things that you don't want to have to deal with, but there's a reason for it. And some people won't take any workers' comp, and I'm here to help you kind of decide whether you want to or not. It's an increased administrative burden. They take longer until they go back to work, they have more office visits. And we figured out that really double the amount of paperwork of a normal patient to take workers' compensation, and that's a price we're going to pay for taking care of these people. And the office staff just has to do a lot more paperwork, and just recognize that it's going to cost you, and you got to decide whether you want to do this or not. But they need more prescriptions, they might need more surgery, et cetera, and you have to document everything. It's interesting that there were more secondary surgeries, and there were new complaints in the perioperative period, but at least they don't cancel their appointments as often. Complications, interesting that they had more problems with the knees or the hips or things like that, and you have to recognize as they get older, they're going to have a tougher time getting back to work. And this is something we recognize with all of our patients. As they get older, it's tough. There's nothing so hard for me as a doctor when I'm taking care of a guy who's my age, who does a very physical labor, he's climbing trees or something like that, and how's he going to get back to doing that? And that's something we face all the time with our normal patient population. With workers' comp, it just gets a little bit more complicated. There is history in this matter. We've talked about this before at the AOFAS meetings. There's certainly enough stuff in the literature, too, about workers' compensation patients, and how it plays a role in disability and figuring out what to do for these people. And I wanted to, during the break, we had a discussion with some of this stuff that this is a learning curve. As you learn to take care of workers' compensation, and you learn the lingo and the jargon, a lot of things that Greg went through today, it's an ongoing process, and you'll get more comfortable with it over time. But for me, it's very important. We see these people because they need a subspecialist. Sometimes these people, they've just been seeing some people who are less adept at diagnosing foot and ankle problems, and these people need help just like anybody else. So I do workers' comp. I limit my workers' compensation population. Mainly my secretary limits it for me, so we don't take too many. And I do IMEs. Why do I do IMEs? Because they pay well, okay? And rarely I'll invoke an option to treat. So we're gonna talk about that at the end. Remember, orthopedics can be hazardous. I don't need to bring this up too many times. Lou was hurting himself here at a vendor, but let's be careful out there. Important issues for your patients. So physical therapy, work hardening, FCE, things like that, and let's go through this. So first of all, physical therapy. One thing that's important to recognize is that these are different patients, okay? The workers' compensation patient was injured at work, okay? He wasn't the skier who got injured in the ski slope putting himself at risk. He was working for somebody who got hurt. And there's a psychological element of being the victim that you have to recognize, okay? And just be attuned to that, okay? Remember, the amount of disability will be compensable at some point in time. And some of these patients will be coached very carefully on what they're supposed to tell you kind of thing. And you just have to take all this into account, okay? It makes it more complicated. It's kind of interesting sometimes, but it can be difficult. In terms of getting into physical therapy, one thing that's in the literature very clearly is timing matters. Get them to therapy, get them going. To get better is important, okay? You don't, you know, and the problem we have with workers' comp is they have to get approval for things, okay, so that, you know, you're gonna send them to therapy, well, we have to get approval. You wanna get an MRI, we have to get approval for that. And that may take a few weeks instead of a couple days kind of thing. And it gets really annoying after a while, but it's just part of the system. You have to suck it up and move along and keep using it and help these people get better. I think it's very important. And just recognize the challenge you're gonna have with it. We found that a lot of times you couldn't even get them to physical therapy for a while, which was, again, important, but we found out that it was important to get them to therapy sooner rather than later. They do better long-term. So what's work hardening, okay? Work hardening is something that you as a physician have to order for your patient, okay? And work hardening is kind of physical therapy and functional recovery. If a guy lifts boxes at a store, they're gonna put him in a work hardening situation where he's lifting boxes and getting back to doing that sort of thing again. And these are specialized physical therapy offices that have the simulated workplaces, okay? And they'll do this stuff for you. You just have to put in the order. That's all you have to do. You don't have to be too specific, say, get them, train them to do what they were doing before. And the repetitive tasks, things like that, mechanics of the job, an automobile mechanic has different demands sort of things. But it's specific physical therapy and you can let the therapist figure that out. You don't have to figure that out as a doctor. They'll figure it out for you. Cycling, always fun. What's an FCE, okay? Sometimes the nurse case manager, someone's gonna tell you, okay, can you order an FCE for this patient now? A functional capacity evaluation is, we think our patient is ready to go back to work. Maybe he's reached MMI or he's plateaued there. And we wanna get an objective measure of his ability to do that sort of work, okay? So you order an FCE, okay? Again, you don't have to be too specific. You say, we need an FCE. And there are specific physical therapy places that'll do this FCE for you, okay? And I got this online, but basically it's just data rather than guessing. And as a surgeon, you can't figure out exactly what this patient needs to do at work. That's what these specific people who evaluate these FCEs will do, okay? But we're trying to get an objective measure of whether they can go back to do their job. And I think it's data, okay, that helps these four people figure out whether they can do this. The treating physician, the adjuster, the claimant, and the claimant's attorney, okay? And to decide whether they can go back to doing the job they were doing before. And again, you go through the, they look at the records, they look at the physical exam, and they see what they can do during these activities to see if they can go back to that job again and what they can do, okay? And it's interesting here that it takes some time to figure these things out, okay? Interesting, this one paper showed two years going through the whole process of getting better, going through the FCE, and going back to work. There's a lot of stuff written about this stuff in journals that we don't read too much. Basically, we're trying to figure out the physical abilities of the worker, the physical demands of their work sort of thing, and kind of outlining and documenting this stuff in kind of a legal fashion that goes beyond the scope of what I do as an orthopedic surgeon. And recognize, again, some of the younger guys are saying, I don't know about this stuff. You'll figure it out as we go along, and they'll help you figure it out as well. But basically, you order the FCE, they give you the information about this. And these, interestingly, these things did have reasonable inter-examiner reliability and validity that these are reasonable studies to use. And again, meetings can be tough too. Sometimes you have to ski with people. You can hurt yourself there. Let's talk about the level of workability. And this is something that you need to know about because you're gonna get this with your patients on a regular basis. How much lifting can they do? How much standing can they do? How much walking can they do? And when I first saw this list, I thought this was something that just kind of, they pulled up out of the blue. But in fact, this is from the US Department of Labor. And it tells exactly, it outlines a number of parameters. How much lifting can they do? And you're gonna have to take a grain of salt with it and not go too crazy with it, but give decent estimates. And I actually sit down with the patient, and I say, hey, what do you think you can do? You think you can lift 20 pounds or 30 pounds? And we kind of write this up. And everyone knows, nothing's written in stone here, but you're gonna go through these forms here. And then, what level of work can they do? And this is something that, is it sedentary, light work, medium work, heavy duty work, or very heavy work? And it's laid out here as to what it is. Again, this is from the US Department of Labor, okay? And it describes exactly what level things are. And you're never gonna know for sure, but you're giving your best guesstimate, okay? And I find it's helpful when I'm taking over a patient who's being treated with workers' compensation, that I go through it with the patient very simply. Hey, you think you can do that or not? Oh, I'll rely on these guys to see what they think about it as well. But I like to have them put some input to it. And then again, the level of workability. How much can they reach? And what's nice about us as foot and ankle guys is usually their upper extremity isn't too affected. And so, it's important to say, hey, they can do the reaching, but they can't be on their feet for too long, things like that. And whether they operate a motor vehicle, can they drive a car? Left foot versus right foot makes a difference for us. Do they have a clutch with a truck or not? Big deal, okay? And this is stuff you're gonna need to address. Can they go back to stuff? But just recognize that there's actually stuff written down about this. There are forms in the U.S. Department of Labor that they're gonna go through. They just need to know about. Again, remember that one, Greg? Way back when, okay? And let's see, return to work criteria, okay? How do you decide as a doctor your patient is ready to go back to work? And again, it's different for the workers' compensation patient than for your guy who fell off the deck in his backyard sort of thing as to when they wanna go back to work, what their financial constraints are, okay? And there's a lot of stuff that goes into these equations, as you know. How long have they been out of work? How old are they? What are they gonna go back to work for? What's their attorney telling them to do, et cetera? You have to figure that stuff out. It gets confusing, but it's part of what you do as a physician, okay? Again, there's enough documentation now that the aging workforce is gonna be harder to take care of. Okay, these older patients are tougher to get back to work. And being an older doctor, it's definitely, some days I wonder about getting back to work, and other days we're fine. But just recognize that's gonna be an issue that you're gonna have to just deal with it. International travel can be difficult for us as well. Return to work criteria. So you're gonna have to decide whether they can get back to doing the job they were doing before. Do they need voc rehab or not, okay? And sometimes you're gonna write for vocational rehabilitation for a patient. And again, the nurse case manager will tell you that. Just write for voc rehab, and someone will take care of that for you, okay? Interesting, there's stuff written about going back to work after ankle fractures. And interesting, what factors go into it? Some of it is social economic status, okay? People who have come from a lower social economic status have a harder time getting back to work. They have more complications. Stuff that you know as a doctor, but you have to address to some extent. And again, this paper was interesting. I was going through this stuff, coming actually out of this location, that the time of work, getting them into treatment is important. Getting them, being kind of aggressive as a doctor, getting them to therapy. Hey, you know, let's get you moving again is very important for getting them back to work, getting them back to a reasonable quality of life. Again, recognize that sometimes the patients aren't gonna be as highly motivated as different patients might be, okay? When they're getting paid to sit around at home, they're not as eager to get back to work sometimes. And you have to take that into account as you're figuring things out with them. Speed meetings can always be good. I just wanna bring this up real quickly. Milliman and Robertson guidelines, okay? These are guidelines that say, if you have an ankle sprain, you should be off work for this long, you should get back to work after this amount of time. If you have a bimedical ankle fracture and it's fixed, you should be off work this much time, and then get back to work kind of thing. And when people fall outside of these guidelines, that's when the red flags are gonna go. And you have to be able to say, well, this is what made this patient different, okay? And this is why we're not gonna follow the basic MNR guidelines on this, because they've got this element going on, or they've got a pre-existing condition that's gonna take them out of the typical MNR guidelines. That's why they're not getting back to work at eight weeks like we expect them to because of this. And you just need to know that MNR is out there, and it's gonna play a role of people deciding whether you're getting them better in time. And I won't go through this too much, just know that it's out there. Let's talk about the nurse case manager, because this is important, okay? You're taking care of a patient's worker's comp, and all of a sudden this nurse is there who might be in the office, might not be, okay? And I've got some patients say, I don't want her in the room with me. She can wait outside. And then, of course, the problem is you need to go outside and talk to the nurse case manager after you see the patient, and say, yeah, I wanna do this, this, let's get them to therapy, or here, let's get an FCO, or what else can I do, okay? What are the patient confidentiality issues, et cetera? And you've gotta work all that stuff out, okay? I basically ask the patient, do you mind if this nurse case manager is in with us while we're going through your treatment? I try and make it important for the patient to know that the nurse case manager is not their adversary, okay? Even though the nurse may be hired by the insurance company, et cetera, to get them back to work, they're gonna facilitate getting everything done. And that's why I wanna get, again, the focus of getting early treatment, getting physical therapy, et cetera, getting them back to a functional status is important, okay? And the nurse case manager facilitates that, okay? And I make them my helper, et cetera. They get things done for me, and that's important to do. But sometimes, and Greg went through claimant versus patient, again, we're talking about the claimant as your patient, okay? But recognize that the nurse case manager is gonna help you get things done. And I always ask the nurse case manager at the end of every patient visit, what else do I need to worry about? What else do we have to address at this visit? What do you need to help the insurer get everything done for my patient so I can get them back to a healthy standard quality of life, et cetera, okay? And I think that that's important to do. And this is just the nurse case manager I work with. We actually wrote a paper on some things, getting back to work. There's some interesting stuff in the literature that when the patient has some underlying pathology, such as anxiety disorders, et cetera, they don't get along as well with the case managers. And I thought it was kind of interesting about that. But patients who didn't get along with case managers had two and a half times more of a problem having something underlying going on there. And recognize that there may be something going on between the patient and nurse case manager that you may have to just address, and they might just go talk to nurse case manager separately, and that's okay. But recognize that they're gonna help you get things done. I think that's important. We can keep going. Let's talk about the adversarial patient, okay? Sometimes the patients don't seem to want to get better, and they're frustrated, or things weren't done well, and they're angry. They don't want to be there sort of thing. They told me they had to come see me because I'm gonna get them better, et cetera, and they're frustrated with everything. And I think you as a doctor just have to explain to the patient that you recognize they're pissed, you recognize they're not happy with everything, but let's go from here. That's how are we gonna work to get you to a better quality of life than you are right now, okay? I need, as a doctor, as your doctor, I need to document what your problems are. I know it hurts when I touch you there, and the pirate was very good about being hurt here, but he managed pretty well. But I need to help you as my patient get you better, okay? And we have to deal with this crazy worker's compensation system to get you better, okay? And I have to document this stuff. I have to document where your problems are so we can get you better, and bear with me while we do this. And most times they settle down with it and they recognize that I'm not working for the insurance company, I'm working as their advocate to get them better. MMI, so you're gonna be asked as the doctor, has your patient reached MMI yet, okay? And MMI is tough to call, to be honest with you, because a lot of people kind of hit a plateau, and they're still gonna get better. Some of these things take a year to get better, but can they go back to work, okay? Is there anything else, do we have a final, can we do a final rating on them now, okay? And there are two elements. One is you know they're gonna keep on getting better for a little bit longer, they're still gonna get healthier, but you also wanna wrap up some of the financial stuff so they can get this check, so they can get on with their lives and sort of thing, okay? And it's a tough call sometimes, just recognize none of this stuff is written in stone, there are judgment calls you're gonna make as doctor, okay? Greg went through impairment a little bit already, the AMA guides we use, I use the fourth edition, and there's a difference between impairment and disability, and you don't need to explain all that stuff to the patient all the time. This is an interesting worker's comp, Fran Farrow at AMA is using the baby to hold her splint as we put a splint on the ER, it's tough. Again, I don't know the legal implications of this, but apparently the baby was okay. Disability we talk about, it relates to the individual ability to do a task or a duty. Again, these are legal terms, okay? One last thing about an IME when options are treated, so I see IMEs, I usually do one or two a week at the end of my day, and you see a patient with IME says, God, you're the first guy who understands what the heck is going on. I want you to be my doctor, okay? And this is an interesting situation, okay? Are you gonna take this claimant as your patient, okay? And on the one hand, it's kind of good, you can cherry pick, okay? If guys really, if this claimant is very obnoxious or very negative about things, I don't think I wanna take care of him. On the other hand, you don't want your IMEs to be a funnel into a way of you just to build up your practice, okay? And see, I'm very careful at any time that I say, a lot of times with my IMEs, I'll say, this claimant needs to be seen by an orthopedic foot and ankle specialist now because the treatment has not been appropriate as yet, and I'll leave it at that, okay? And I'll let them come to me later, okay? Or if the claimant is asking me directly, hey, can I come treat with you? I want you to be my doctor now. I'll say, well, I'm not supposed to be taking you directly to the patient. You can talk to your lawyer about that, and we can address that maybe a little bit later on, okay? And be careful about this, but it is a way that you can take new patients on, but be careful about it. But you're gonna see people, when you do IMEs, who have just been, somebody just missed the boat, okay? And you say, this patient, this claimant needs to be treated appropriately, and luckily, I'm in Baltimore. There are plenty of good foot and ankle specialists, and I'll say, you need to be seen by, here, there's someone at this hospital or this hospital, or one of my partners can take care of you, but I'm not supposed to be taking you as a patient, so this is what I recommend, this sort of thing. And that's fair to do. Lecture can be tough, too. And I think, remember that some of this stuff does get into the literature, too. Richard Buckley was writing about calcaneal fractures, and he talked about workers' compensation, and a lot of stuff can get into academics, as well. And we'll stop there. Thank you. Thank you. Next up, we have Dr. Jason Aguero, who's gonna be speaking about what can return to sport teach us about return to work. Good morning, everyone. It's been an interesting morning so far. I'd like to thank Dr. Guy and Dr. Coleman for the opportunity to speak to you guys today. I'm gonna be talking to you guys about what can return to sport teach us about return to work. These are my disclosures. This is my disclaimer. I'm not really a high-volume work comp doctor. In fact, I really only work as a treating doctor only, and select foot and ankle cases. I really don't do IMEs. I have, however, treated a lot of athletes, military and veterans over the years. And this talk is really an attempt to kind of reframe the way we approach return to work decisions, kind of drawing parallels from the return to sport situation. So on any given Monday in my clinic, we see athletes of all levels, injured workers. We have average Joes that got hurt over the weekend with insurance that need care. I see military and veterans, as well as some government employees. And really the purpose here is we wanna learn, what can I learn from the treatment of an NFL quarterback, for instance, and how can we infer what we do in terms of the evaluation and treatment of these patients and in terms of trying to get an injured construction worker or lineman back to work. And really should the context of the injury affect the evaluation and treatment course? My suggestion is yes, it absolutely should. And I think that treatment is gonna involve balancing. Really with every evaluation treatment decision, there are three factors. There's a risk, there's a reward, and there's a cost. And I think you have to take all of those into consideration. So we heard earlier from the history talk, Otto von Bismarck. He's the father of a modern day work comp system. He was a Prussian general at the time. He really emphasized that the work context emphasizes rehabilitation. We also have talked a lot about pirates today. And we know that for those that missed some of the earlier talks, we know that original work comp systems were developed within the pirate world where pirate ships were really operated as meritocracies. And that work comp schemes for injury and battle were created to add further incentive for these pirates to return to battle. This always included a vocational rehab. So if one was working as a sail rigger, they may do something else after that. Really sports and the military also emphasize rehab. Hence the purpose of this talk. So really lessons from sports medicine. What can we kind of infer from the evaluation as well as return to activity for an athlete? And how can we kind of carry that into our treatment of the injured worker? So in terms of this talk, initial evaluation. So in general, in a high value sport, we tend to rush to advanced imaging. Reason being is the cost is negligible compared to the investment in that player. The rest of us, for anyone else that gets hurt, work comp included, we kind of go by the Ottawa ankle rules, which have been around for a while. They basically say that x-rays are required if someone's inability to bear weight in the ER or they have pain in any of the specified locations, which include the malleolar zone, base of the fifth metatarsal, pain directly over the tarsal navicular. Those patients need imaging. These Ottawa criteria were validated for specific fractures only. So they really meant to identify significant malleolar foot fractures, and that's one that require immediate treatment. So what's not in them? Bone contusions. We all know that an ankle sprain with large bone contusions of the talus or malleoli, those patients take a lot longer to get better. Osteochondral injuries. Other fractures, so anterior calcaneal process fractures or lateral talus process fractures. Those don't really get picked up by Ottawa. Occult leg and meniscent injuries, such as a lisp fracture. We really only see those on a weight-bearing x-ray. So these criteria really do contain an inherent delay in diagnosis for these patients. So what is the harm with that? Biggest one is probably a cost and loss in time, loss of revenue and ability to get back to work. We know that early appropriate intervention increases the chance of success. We know that if injured workers are out for longer than six months, they have about a 50% chance of returning to their previous job in really any capacity. We know that managed return-to-work policies reduce the chance of ultimate failure. So early, accurate diagnosis is the key. I think it's also important to establish a baseline for future injury evaluation. For instance, a footballer's ankle where you've got a soccer player that's had numerous injuries over the years. They've developed osteophytes and so forth. It's really important to know what their baseline is so we know if we can attribute a future injury to something acute. However, we often know a lot less about the immediate pre-injury status of an injured worker as we do an athlete that's been seen by team doctors and been screened over and over every season. Appropriate imaging can establish a time course. We know that degenerative changes can take a long time to occur after an injury. We know that injury events can potentially be excluded as a cause. For instance, Achilles thickening. We know after Achilles strain, partial tear, it can take up to six months or so to develop these changes. So earlier MRI in this situation potentially would differentiate a more acute injury versus a chronic one. So what's the lesson? There's compelling reasons to collect early objective data in the course of a work injury episode. The other trick is getting a carrier to pay for it. So how fast should we do it? Well, I think it's condition dependent. I think it's really as soon as any significant branch point in your treatment algorithm is reached. It should be well before any acute and chronic degenerative changes become indistinguishable. So let's take, for example, an ankle sprain. I think in most situations, six weeks is probably a reasonable time frame to obtain an MRI if somebody is still symptomatic. Purposes for this would be to direct treatment. So we know that immobilization of a bone contusion is probably more helpful than physical therapy. We know that a displaced osteochondral lesion really probably needs early surgery. We know that peroneal tear may direct your physical therapy and modify your protocol slightly. We also want to establish a baseline. We know that by three months, any bone edema associated with an acute OCD is likely to start to fade on an MRI. And so it's going to be later difficult to establish whether this is an acute problem or a more chronic one. Secondary lesson is that it costs about the same amount to the work comp carrier to obtain bad musculoskeletal imaging as it does to get good imaging. So you want to try to get the best you can, meaning don't refer to 0.3 Tesla MRI when you can get a 1.5 versus a 3T. Other lessons, you want to make sure you order the right modality first. So if I'm looking for somebody that has a capsular injury to the MTP complex, we want to make sure we get a turf-toe protocol type MRI with fine cuts through the forefoot there to be able to differentiate these injuries. We want to use extremity coils if possible, all things that we all do in our practices normally. Secondary lesson is that when you can get weight-bearing imaging, you should get it. If a patient arrives with images from the ER that are almost invariably not taking weight-bearing, you want to get them to repeat those images so you can differentiate colic ligamentous pathology there. If you do have access to weight-bearing CT, which is becoming more commonplace, getting a weight-bearing CT can really be helpful if you're looking for chronic degenerative changes. For instance, in this image on the right where you can see that with weight-bearing CT, you can definitely see advance of tailor arthritis, which you really wouldn't see on the non-weight-bearing CT. Let's talk about timing of return to work and sport. So getting an athlete back to play. I wish it was clear cut, but as we all know, it's not really as clear as we would like. There's a lot of different standards that we use, and really, the return to play criteria are specific to the pathology that they're dealing with. It's really best when we have a metric to define when they're ready to go back. Potential metrics we often use are minimal timelines, functional tests and neuromuscular tests, functional patient-reported outcomes measures, as well as psychologic PROs. The problem is, in a lot of our literature, there's an absence of metrics, which, especially if return to play is used as a criteria, can make it difficult to interpret these studies. For instance, this study looking at suture tape augmentation after Brostrom, they had a primary outcome measure was time to return to pre-injury level of activity. Well, that is important, but what they don't have is really what criteria were used to determine whether that athlete was ready to go back. As we all know, athletes return to play when we tell them they can. So, if we don't have objective measures, it's really hard to apply that. So, let's look at two different models. We'll look at the ACL tear data, as well as ATFL tear. So, ACL tear, they've got multiple validated metrics for return to sport. Typically, minimum timelines are somewhere in the range of six months. Younger athletes often are seven to nine months. We know there's some validated instrument testing that can be done, such as quad testing. We know that you want to have at least 90% of the uninjured side in order to be ready to go back. There's also various neuromuscular tests. So, the hop test is a very common one. You want to be at least 90% of your hop distance from side to side, as well as timed hop. You want to be within 90% of your time on doing that, as well. We know there's also several validated PRO-type measures. There's the knee outcome score, activities of daily living schedule. We know that you want to be at least, again, 90 percentile or greater on that. And there's also psychological PROs that can be used, such as the ACL, return to sport after injury scale, which asks questions like, how confident are you you can perform at your previous level of sport? Do you think you're likely to re-injure your knee when you go back to sport? I think all these are really important to know what the athlete's psychological state is as we try to get them back. So, these tests really serve to determine reliability and validity for return to sport. They're not as good at predicting re-injury, however. We know that the study that looked at journal of orthopedic sports physical therapy looked at this. They did a large meta-analysis, a return to sport after ACL. And they actually found that there's a non-significant 3% risk reduction for second ACL tear, even when you pass these return to sport criteria. Unfortunately, the rate of ACL re-tear is pretty high. We look at chronic ankle instability. There's really no validated metrics for return to sport. Dr. Guyton and his group did a systematic review of this, where they looked at 23 articles on Brostrom procedure, where return to play was mentioned at about 2,500 patients amongst this cohort. Only about two out of 23 of these studies had any specific return to sport criteria. So what are some possible metrics for this? Can we use stress radiography in the office to determine, you know, is somebody stable and ready to go back? Well, that's probably not great, right? It's not very reliable or reproducible. Patients guard. And really, there's no objective criteria for what's normal here. So what are some possible candidate metrics that we can use for these ankle patients? So instrumented strength testing. I think that's something that can be pretty easily employed both in the office as well as in physical therapy setting, which gives us some idea of, you know, what a patient's eversion strength is, which we all know is really important when we're deciding whether they're stable enough to go back. I think probably even better tests would be an integrated neuromuscular functional test, such as the STAR excursion balance test. And for those of you guys that aren't familiar, this is one that often gets employed in the PT setting, but basically it's an eight-point star that they tape out on the ground. Essentially, it measures dynamic postural control in the lower limb. You have the patient balance on their injured side, and then you have them reach out at these eight different points as far as they can. And what you're looking to see is what their stability is like on their injured ankle as they balance on it, and then you want to compare it to the uninjured side. So you repeat it and have them go the other direction. And really, you're looking for asymmetry with the distance that they can step out and point at those various points. So a difference of greater than about four centimeters is thought to be significant and probably not ready to return to sport. What about PROs from a functional standpoint? So we have the AOFS Heinfeld score, which we're all familiar with. Everybody uses it. It's probably the most commonly used. It's really not validated, however, and it's the mathematical structure of it's a little bit irregular. And really, it's never been shown to be associated with successful return to play. What about PROMIS scores? So the PROMIS physical function and pain interference, these can be employed through computer-adaptive testing, which can make them very easy to employ in the office and efficient. I think that's potentially a good candidate there. What about psychological PROs? Well, we don't really have a good one. It's bottom line is we need better metrics in foot and ankle, and we need to start measuring them routinely. So what metrics can we use to evaluate the injured worker? So obviously, we all use our physical exam. We use our PT evaluations and notes. I get a lot of feedback from that in terms of how some of the workers doing and when they're rehabbing. We have minimum timelines, where we think they should be. And as Dr. Miller pointed out earlier, there is a guide that sets pretty standard time to return to work that you can kind of use as a resource, but obviously, there's some variance in that. And then there's the FCE, which Dr. Miller also talked at length about. FCE is really our gold standard, but it does have limitations. There are multiple accepted formats and methods for this. The behavioral assessments can be difficult to validate, and they really rely on internal consistency. They're expensive, and really, we don't employ them in every case. They're really only used in problem cases where the worker is still having a hard time getting back. Really done at the end of treatment, of course, and so we really can't use them as a tool to assess longitudinally how that worker is doing in the course of their recovery. In terms of validation, really to be valid, they should have both content and criteria and validity. You know, in terms of content validity, really it's a subjective measurement. It really requires the evaluator to have a good understanding of what that worker's job entails and what kind of physical tasks they have to do. Criterion validity is rarely present, but it's really most clear in simple lifting tasks. So even when we accept that the FCE is our gold standard, there's still some gaps. You know, not everybody needs this test, and so we don't just blanket send everyone for it. And they're really typically done at or near MMI. If we could have an earlier evaluation with simple, repeatable tests, that may allow for better tracking of treatment efficacy. So what are some lessons from a sports return to play? Sometimes absolute time minimum are important, sometimes they're not. We know that simple, repeatable functional tests offer significant value, but they're rarely done. We should be looking at both static strength, range of motion, as well as integrated neuromuscular tests. Functional PROs can help, and can be efficiently done. We know the PROMIS system, which was developed by the NIH with their assistance, and it's now run by a non-profit. It's a computer-adapted test, five to seven questions, can be done through an app-based questionnaire, patient IQ, REDCap, any of these, which are, even through Epic nowadays, you can do this. They're generic instruments, so they can really be applied across a variety of pathologies. And when you look at the scoring of this, we assume that there's a population mean of 50, one standard deviation is 10 points. When you look at physical function, we know higher score is better, and the pain interference scale, we know that a lower score is better. Both of these are prime candidates for PASS score threshold determination. And what is a PASS score, you might ask? So PASS stands for patient acceptable symptomatic state, and this is an alternative to what we call the MCID, or minimally clinically important difference for determining treatment success. It kind of relies on the hypothesis that it's more important to feel good than to feel better. And I think it's got potential for developing thresholds for return to work. We can't really neglect psychological PROs. In conclusion, treating workers more like athletes has parallels in both the initial evaluation and return to work decisions. Evaluation should include objective early data, even if there's extra cost up front, and sometimes you've got to convince, you know, someone from work comp that you really need this MRI, but I do think the earlier information can be helpful. This is both important for guiding your treatment as well as for long-term apportionment when you're trying to decide an impairment. Simple modifications in our evaluation, including getting weight-bearing imaging when we can, increases the ability to distinguish chronic versus acute disease, really at no extra cost. The SC is not perfect, but it's our best effort, and unfortunately, it's too cumbersome to do for all cases. Return to sport evaluations are far from perfect, but some are better than others, and I think that if we can look at our sports medicine colleagues, you know, we really can see that the ACL protocols are probably some of our best models, and if we could try to mirror those with some of the protocols we have in foot and ankle, I think we could be better. I think there's potential to incorporate repeatable, frequent, and inexpensive tests of just function, as well as static strength, range of motion, and neuromuscular function, as well as PROs of functional and psychological status through computer-adaptive testing. That's it, thank you guys. Oh, I'm losing my microphone. All right, well, thanks, Jason, that was great. Well, first of all, that's where we're gonna end for this morning, so if anybody has any questions, please feel free to come on up. Yes? Work hardening versus work conditioning, what's the difference? Stu, would you like to address that one? The question was work hardening versus work conditioning. I'm not exactly sure, to be honest with you. I can see. Work, they're kind of the same idea, you're trying to get them back to doing the job they were doing before, or what can they do? Do you have a definition, Vern? No, I don't, work conditioning is a less specific term, the way I think of it, I think it's a semantic difference, but I've seen both terms used. So work hardening typically implies daily attendance, usually for a minimum of four hours a day, and that's the way I conceive of it. Work conditioning is just an acceleration of standard therapy, but I have not seen that to imply daily attendance, and so the difference is standard therapy is usually two or three times a week. Work hardening is like a job for them, and the patient has to go every day and simulate job tests for at least four hours, usually half the time. We appreciate the talk, lovely topics. For a patient who has spine fractures and foot and ankle pathology, how does your, and they come with you paperwork for paternal work, bending, squat, et cetera, how do you handle that? Usually I only do the paperwork that's referred to their foot and ankle, and so I have that advantage because they know I'm a foot and ankle specialist. You can decide if you're gonna be more of a general orthopedist if you're willing to do the other papers. It becomes tricky. If you're not the treating doctor for that problem, I would not suggest that you address that return to work issue, and you have to basically say that my opinion is limited only to foot and ankle. Other thoughts, guys? Yeah, I'm very careful about that, is that even when I'm doing IMEs, I'm only addressing the foot and ankle issues, okay? I stay in my lane, okay? It's very important when you're doing medical legal things to stay in your lane, okay? Because if you get out of your lane, you're gonna get burned later on because they're gonna say, oh, when's the last time you took care of, you know, the spondylolisthesis at L4, L5, and it'll be like, well, okay, it's been a little while, but I understand it, and yeah, you do understand it better than maybe some of the DPMs out there, but stay in your lane, stay safe. Again, this is medical legal stuff. Yeah, I mean, it's a little bit different if you're an evaluator, if you're an IME, than if you're a treating doctor. You can be a little bit more relaxed about that because the treating doctor doesn't have the same requirements as the evaluator in an IME, but Stu's right. Tend to stay in your lane a lot more when you're doing this, and so it becomes pretty simple. Even if it's simple things like am I gonna order, am I gonna order physical therapy for their trochanteric bursitis? Typically, in a work comp case, the answer is no because that could lead you down some very difficult pathways. Any other questions, yes? Great talks, Scott Swanson, Lincoln, Nebraska. How do you handle the foot and ankle patient who says they've been unable to bear weight normally for three months, and now their knee, their hip, and their back hurts? How do you go about making referrals for that patient? Do you comment on causation, and do you have any evidence to back that up? Appreciate your comments. Yeah, that's a good question because we always see, oh, my foot hurts, I've been in a boot, now I got all these, now it's going up the kinetic chain, and of course, you see our podiatry colleagues sometimes prescribe orthotics for that. So how do we handle it? Jason, you wanna comment? It's really common, I mean, we all know that. Sorry, you're not mic'd, so speak way up. No, your mic's not on, but. Or just shout. I'll stand closer so you can talk to me. Yeah, so Greg, it's a good question. I think that we see this a lot. Somebody's been in a boot for a while, they start getting contralateral knee and hip pain, and honestly, I initially try to incorporate that into their rehab. I'll attempt to treat it. If I know it wasn't there at the time of the injury, I still think it's kind of an add-on in the sign of work. It does get a little sticky, I agree, though. Particularly if they start having sciatica. I guess at some point, if they don't improve with simple PT, I will refer them to a knee or hip specialist, but it is tricky when it's not, we didn't capture that as the initial problem, and now this is sort of a add-on thing. I don't know if that's right or wrong. That's how I've approached it. Sue, you look like you have a comment. Yeah, one of my slides had a picture of that these worker's compensation patients are gonna have a higher degree of complications of other joints and other things that are gonna be involved. You're gonna have to make that referral. Yes, because they were walking funny, they irritated their hip, and now I wanna see PM&R or something like that, or hey, I want them to go see my sports specialist about their knee. Just document it, be honest about it, and make the suggestion. They're still gonna have to get approval to see them that somebody else's problem, it's not my problem. I can just make the recommendation. There are two adjacent specialists that I find incredibly helpful in dealing with work comp as a treating doctor that weren't honestly around very much when I was a resident. One is PM&R, which can be incredibly useful for that situation, where they're complaining of multiple joints, including back and hip girdle and shoulders and things like that, often non-operative. The other is there are populations of plastic surgeons that are now doing mostly peripheral nerve work, and there can be situations where they can be very useful. It's not that I can't do a tarsal tunnel, but in some of these more difficult, complicated comp patients, I'd honestly rather that a nerve person do it, and I make use of those guys. Yep. When it comes to timelines and return to work as a treating doc, how do you address the occupation? Like a roofer or a laborer compared to someone who's at a seated desk job, or even the laterality, that they could get back to work at a seated position, but it's the right foot and they can't drive. Is that something you get involved with, or do you stick to the medical aspect? Well, I'll pass that on, but I'm also gonna ask the same question, the Millman and Robertson guides, which, to be honest, none of us have ever seen, to my knowledge. I may have seen the book once. People aren't aware that this thing exists, and the insurance companies are keenly aware that there's this clinical guideline that they are using to determine how long they're gonna keep paying for physical therapy, how long they're gonna keep paying for treatment. And so this is a question. It's the same question in the sense of impairment versus disability in an IME. Impairment's what's wrong with you, disability is how what's wrong with you affects how you can do things. How much should we get into that as treating doctors? Should we treat construction workers different from office workers? Stu? You know, we only have so much information at our fingertips, okay? You can only be so much of an expert. I mean, we are the godly surgeons after all, but in reality, we just have a vignette of what their life is like. There are professionals who are trained to go out to the workplace and see what's involved with this person's job and make a decision as to whether they can go back to work or not. And that's not on my rear end. I don't have to make that decision, okay? I can say, I think they should be able to go back to doing this. I think it seems reasonable they could go back to their job as being a delivery person, but I don't think they can lift a 40 pound box or something like that. And I'll say, this is what I perceive, I think they should be able to, but I'll leave it to the experts to decide whether they actually can or not. I think my answer to that question is I make extensive use of the OSHA categories in partial work release. And so there are times when the construction worker comes in and says, I don't want to be released back to work, I can't do this job. And I will release them to sedentary duty or light duty with a restriction of a 10 pound weight lifting restriction and no repetitive climbing of stairs, no exposure to ladder or heights, some reasonable things that would allow them to do some aspects of their job. Perhaps they can do finished carpentry, but they can't do outdoor construction. And then what you're doing is you're shifting the onus to the employer by making statements that you feel you can medically justify without what Stu's talking about is you cannot be some omniscient person that knows everything about their employer and their job situation. And I think that's a fair way to address it. So I make extensive use of partial release, but I also know that as a practical matter, many of those patients that I partially release, the employer can't accommodate the restrictions. So, go ahead. Thank you. As a treating physician, oftentimes after a patient has an IMA and a rating, they come back disputing that. And I've just wanted to know how you handle those situations. Thank you. Sure. Who would like to comment on that? How do you handle a disputed IME and a rating? And I'm talking about a rating from another provider, I present, yeah. So if they come back and dispute, they got a rating from another provider. You know, again, you only have so much of a role to play in this medical legal game that's going on, okay? And you say, wow, that seems pretty superfluous rating for the injury that I think you've had. You know, talk to your lawyer about this, but it's not up to me to make this rating. They haven't asked me to do that sort of thing. Jason, you look like you're about to say something. Michelle, please. Well, I think if we've sent them for their MMI and impairment rating, that's one thing, and they come back with that. I mean, at least in Texas workman's comp, there's a specific process where you can and you either have to agree or disagree. If you disagree, well, they're entitled to a second one, but if whatever they get on that one, they don't get the best of the two. It's not the SAT. I mean, they basically have to take that second rating. So if they get rated lower, they bought it at that point. What I usually say is, look, this is not a, we have a system where I've talked to more this morning about everybody knows who the plaintiff-friendly IME doctors are, but there are also defense-friendly IME doctors, and we sort of rapidly learn who they are in the community, too. I advise everybody in this room to play it down the middle, because that's how you gain credibility. It also, it really helps you gain credibility if you're ever deposed. If you are the IME doctor who plays it down the middle, if the carrier is on another case, they will sometimes refer to other cases, say, doctor, how many IMEs have you done for me? How many times have you actually recommended that that patient have surgery? And sometimes the answer will be a lot. So you may not be the, you don't wanna be seen as the most plaintiff-friendly or the most defense-friendly IME doctor. If the patient comes, if the claimant comes back, you're the treating doctor, and they're unhappy with a defense-friendly IME that they got, perhaps from one of those people you know is very defense and gives everybody 5% ratings, regardless of how bad it is, there are times when that person needs to find a work comp attorney, and quietly suggest that. I think we better take one more question, and then move on. How do you handle when someone has restrictions you've given, like you did for the construction laborer, and then they come back in the office and say they're not following the restrictions that made them do certain things? I don't know. I wish there were an easy answer to that. It is common, it's very common that they will dispute the restrictions, not dispute the restrictions, but dispute their employer's compliance with the restrictions. That happens a lot in retail and construction, happens in retail all the time. If you give them time-limited restrictions, if they have to take such a break off their foot every hour or two hours, and they'll say, well, we're just too busy, I can't do that. That you can't be their lawyer. And so at the end of the day, you have to tell them this becomes ultimately a matter for your attorney, because you cannot become involved, and you don't want to become involved in tit-for-tat notes that you write back and forth that's saying, well, I don't think they are following the restrictions. You only have one source of information. Don't become the attorney. You have to stick to your lane, is the advice I would give. All right, I think we better wind up the morning. I'm going to leave it there. Just a quick reminder, we do have a welcome reception tonight at 4.30. That's just a general reminder. We're coming back for an afternoon session here. We'll be back at 1.30. We're going to cover some pretty critical information there for those that want to deal with this. I know it's an exciting topic, but it's actually a necessary topic. We're going to talk about pain and how to objectively deal with the concept of pain versus malingering. It's an incredibly important topic. We'll start with that. We're also going to get into the impairment rating. And you really can't be involved in the work comp stuff without understanding impairment ratings. Brad is going to give us a little bit of a bonus. He's going to do a discussion on cost estimation, which is also an important topic that will occasionally come up if you're dealing with medical legal work on cost information. And then we're going to have a model deposition so that you, if you have never been deposed, if you haven't seen how that works, we're going to show you how to interact with lawyers on a model deposition. We actually have a real lawyer who's going to zoom in for us. And then lastly, Celan is going to tell us how to integrate comp into your practice. And that's going to be practical discussion because comp, if you integrate it into your practice, can actually give you a lot of flexibility with different financial settings that you can set up in terms of tax advantages and things like that. So he's going to touch on some of those things with the caveats that we're not tax advisors, but he gives you some ideas of what to do. So we do have a very, I think, pretty exciting session coming up this afternoon. That'll start at 1.30 after lunch. Remember, lunch is available outside and in the lobby outside the session room. The fellowship fair, I think, is at noon. And one last thing, the AOFAS Foundation is hosting a raffle, including prizes of three weeks to the winter meeting in Lake Louise, or three days at the Lake Louise Hotel and a $250 gift card, free nights in Savannah, Georgia, and a Pittsburgh sports experience coming from Baltimore. I don't know why anyone would want that. Sorry, Stu. But I think we are, I think we're going to adjourn for the morning and see you all back at 1.30.

workers' compensation

treating physician

administrative burdens

physical therapy

functional capacity evaluation

nurse case manager

psychological elements

impairment ratings

non-compliance