Return to work after foot and ankle injury

Return to work after foot and ankle injury

Molly Kunkel, RN, Stuart D. Miller, MD*

Department of Orthopaedic Surgery, The Union Memorial Hospital, 3333 N Calvert Street, Suite 400,

Baltimore, MD 21218, USA

Foot and ankle injuries are common in the workplace, and every surgeon sees

patients who were injured on the job. Return to work is critical to all involved, but

the potential for inefficiency and possible substandard care is high because of the

involvement of several parties in this scenario. The requirement for brief but

frequent communication with other members of the treatment team may tax the

systems in place in physician offices. The physician treating workers’ compensa-

tion patients may benefit from close coordination with the workers’ compensation

case manager to help maximize the desired results from the effort of all involved.

Dobyns [1] notes that the three stages of most workers’ compensation injuries

are (1) the initial sequential treatment, (2) rehabilitation, and (3) the return-to-

work agenda. He suggests that these stages should be under the control of a

physician, preferably the same physician. Although this centralized approach

may have certain benefits, the outcome for rehabilitation and return to work in

these cases depends on communication and cooperation among the employee, the

employer, the insurance company, the physical therapist, and the nurse case

manager. An enhanced understanding of these interactions is important to the

orthopedic surgeon, who plays an important role in helping the patient recover

from injury and in determining the injured worker’s return to work status.

Diagnosis and treatment protocols

Appropriate diagnosis and treatment is an important part of treating injured

workers and returning them to work. Geppert et al [2] note that missed diagnoses,

often by a generalist or by an orthopedic surgeon not skilled in foot and ankle

care, can be severely limiting to the patient’s recovery, and fractures to the talus

and the lateral hindfoot may prove especially difficult to manage properly. This

study suggests that subspecialists should see workers’ compensation patients.

1083-7515/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.

PII: S1083 -7515 (02 )00031 -1

* Corresponding author. Stuart D. Miller, MD, c/o Lyn Camire, Editor, Union Memorial Ortho-

paedics, The Johnston Professional Building, #400, 3333 North Calvert Street, Baltimore, MD 21218

E-mail address: [email protected] (S.D. Miller).

Foot Ankle Clin N Am

7 (2002) 421–428

The difficulties in diagnosing orthopedic foot and ankle problems can be seen

when treating work-related injury. An orthopedic generalist may miss subtle clues

to the pathology of lateral foot pain, whereas a foot and ankle specialist might

take more time to clarify the elements of injury causing pain. This stage of

diagnosis is often where return-to-work failure begins. Many times the injured

worker has spent weeks and sometimes months without a specific diagnosis and

without appropriate treatment, resulting in failed attempts to return to work before

seeing the subspecialist. This process may give the mistaken impression to the

insurance company and the employer that the injured worker is malingering and

does not want to return to work.

It is important for the physician to set the stage for return to work at the initial

contact with the patient, reinforcing the idea that the outcome of the treatment plan

is a return to work and to daily activities as quickly as possible. For some foot and

ankle injuries, it may be important to set target dates for return to work that are re-

evaluated at follow-up appointments. These target dates should be based on the

physical examination, information obtained from the physical therapist, and the

case manager’s input regarding the availability of modified duty.

The workers’ compensation insurance companies and case managers use The

Medical Disability Advisor for disability information on a variety of diagnoses

[3]. This source helps in estimating the projected cost of the injury to the

insurance company and projects the length of the disability (Table 1). The book

describes how the problem is diagnosed and treated, possible complications,

predicted outcomes after recovery, possible work restrictions and accommoda-

tions, and type and frequency of rehabilitation that might be recommended. For

example, for a fracture of the lateral malleolus, physical therapy is expected three

times a week for a period of 4 to 6 weeks and expected length of disability for a

job classified as heavy work is 42 days.

It may be necessary for the physician to schedule follow-up visits with the

injured worker more frequently in the beginning of the treatment plan to return

the injured worker to employment as soon as possible. For example, if sedentary

work is available to the worker, it is estimated they should be able to return to

work sometime within 7 to 42 days after the injury. The physician recognizes

issues that may delay recovery and return to work. These details should be

Table 1

Expected length of disability based on job classification for medial or lateral malleolus fracture.

Expected length of disability (days)

Job Classification Minimum Optimum Maximum

Sedentary work 7 14 42

Light work 14 28 56

Medium work 28 56 84

Heavy work 42 84 112

Very heavy work 42 112 168

From Reed P. The medical disability advisor: workplace guidelines for disability duration. 3rd edition.

Boulder, CO: Reed Group; 1997; with permission.

M. Kunkel, S.D. Miller / Foot Ankle Clin N Am 7 (2002) 421–428422

discussed with the case manager, who then can relay this information to the

employer and to the insurance company to help alleviate unrealistic expectations

regarding the patient’s recovery period and estimated return-to-work time frame.

When return to work is first discussed, the injured worker is often unaware that

a modified duty program at work is available. The physician can consult the nurse

case manager on this topic. The case manager is the one member of the treatment

team whose job is to be in contact with all the parties involved with the injured

worker’s claim. The nurse case manager discusses the treatment plan with the

physician and acts as the patient advocate, as in confirming that the injured worker

understands the treatment plan. The case manager also speaks with the employer

to discuss modified duty availability and then communicates this to the physician,

who can help to determine the physical limitations and restrictions of the injured

worker. The case manager contacts the employer to discuss the physical limi-

tations and work restrictions and the employer’s ability to accommodate the

restrictions. If the employer is unable to accommodate the physical restrictions,

then the injured worker is unable to return to work and continues to receive the

workers’ compensation temporary total wage and medical benefits. If the

employer is able to accommodate the restrictions, the injured worker returns to

work in the modified capacity, the medical benefits from workers’ compensation

usually continue, but the weekly wage is resumed by the employer. Employers can

avoid high insurance premiums by providing modified duty for the injured worker

during the expected length of recovery.

Often the worker with a foot and ankle injury is restricted from driving, but

many insurance companies or employers are willing to provide transportation to

work for the injured worker if they are unable to drive. These arrangements are

coordinated by the case manager.

Return-to-work strategies

A return-to-work can consist of full or modified duty. Some patients are better

returning to full duty but with a limited work day. Others are limited by physical

demands to what they can do over the course of the work day. The limits should

be gradually extended to full activity over a planned time frame.

A return to work is clearly beneficial in terms of overall workers’ compensation

costs. One study of patients being treated for chronic pain found that those patients

who were directed to return to work during the treatment program had fewer

compensation benefits and received less additional treatment for their pain [4].

The difficult ankle and foot injury may require a team approach to coordinate

a return-to-work effort. The treatment team involves the physician, the physical

or occupational therapist, and the case manager. If the physician recommends

therapy, the case manager is able to assist in the initiation of the therapy by

obtaining approval for the services from the carrier, eliminating a delay in the

physical therapy services for the injured worker. The case manager discusses the

progress of the therapy with the physical therapist and then communicates any

M. Kunkel, S.D. Miller / Foot Ankle Clin N Am 7 (2002) 421–428 423

concerns the physical therapist may have at the physician follow-up appointment.

The physical therapist may recommend a specific modality to the case manager,

who relays this recommendation to the physician.

The influence of workers’ compensation benefits on outcome after surgery is

well documented. One study found that patients on workers’ compensation had a

significant increase in the number of postoperative visits, amount of therapy, and

time off from work [5].

In a study by Maier [6], most workers’ compensation injuries were minor and

only about 10% of the injured workers were determined unable to return to their

regular work. For severely disabled workers, Maier [6] found that those taking

advantage of return-to-work options (such as sedentary or light duty work) had a

higher rate of re-employment. The workers who did best were employed in light

duty (with an employer subsidy program) while their claims were being settled,

as compared with those who settled their open claims in a claim disposition

agreement. The benefit of modified duty lasted for years, with almost 75% of

those workers who started back with light duty continuing to be fully employed.

The drive to return to work is much more than a simple need for the employer

(or the insurance company) to limit paid time off. Statistics confirm that

prolonged time away from the workplace can be detrimental to the patient’s

recovery. The Work-Loss Data Institute’s ‘‘Official Disability Guidelines’’ [7]

note that the longer a worker is off work, the less likely he or she will ever return

to work. For those off work 3 months or less, 75% return to work. For workers

off the job for 6 months, 25% return, and for those off work for over 12 months,

only 5% return to work [7].

When a gradual improvement in abilities is expected, the physician should

guide the process. Physical therapy helps to improve range of motion, strength,

and endurance. As the patient completes physical therapy and begins to return to

normal activities, but is not quite ready for full-duty, full-time work, the work-

hardening process provides a specialized form of therapy designed to simulate the

workplace and improve the worker’s endurance. Work-hardening programs have

been demonstrated to be cost effective and important in returning the patient to

the job [8].

The barriers to return to work extend beyond physical barriers. Work-hardening

programs seek to aid the patient to deal with psychologic issues of returning to the

workplace [9]. If the injured worker is not able to return to his or her preinjury

position and needs vocational rehabilitation, there are tools used to predict the

success of vocational rehabilitation efforts. One study of patients undergoing

vocational rehabilitation under workers’ compensation found that the Beck

Depression Inventory was the most important predictor of return to work [10].

When the actual abilities of the patient are uncertain, a functional capacity

evaluation might help determine whether the patient can meet the demands of the

workplace. This evaluation is prescribed by the physician and carried out by a

physical therapist who has special training in occupational issues. The experi-

enced nurse case manager can often help the physician determine which course of

therapy is most beneficial, work-hardening or a functional capacity evaluation.


Strategies abound for returning the patient to the workplace. For example, if a

carpenter who walks on elevated 2-by-4 wood beams sustains bilateral calcaneus

fractures, is he unlikely ever to return to such construction activities? The

physician might say no from the start and recommend vocational rehabilitation

sooner rather than later. If there is uncertainty, this question might best be

addressed by a physical therapist who specializes in orthopedic injuries after

rehabilitation efforts have been completed. It may be necessary to have the injured

worker complete a functional capacity evaluation. The evaluation provides the

physician concrete data on which to base the worker’s work limitations. Based on

the examination, it may be determined by the physician and the physical therapist

that the injured worker could benefit from a work-hardening or work-conditioning

program to bring him or her to a preinjury physical level. The injured worker may

overcome some of the limitations identified in the initial functional capacity

evaluation and may actually be able to return to work at the previous level of

employment with some minor modifications, which are identified by the evalu-

ation administrator.

If the patient is unable to meet the requirements of the job after these strategies

have been used, it may be necessary for vocational services to be recommended.

One must be careful when discussing vocational rehabilitation with the injured

worker. Vocational rehabilitation to the injured worker may conjure up ideas that

they will be retrained for a computer job or a position that they have always

dreamed of holding. In fact, vocational services usually means that they are given

assistance on writing a resume and job searching for positions that fit within the

restrictions identified in the functional capacity evaluation. This does not always

mean that the job they are physically capable of doing after the injury is the same

pay rate as preinjury.

It is advisable for the surgeon or physician to avoid becoming entrenched in the

mechanics of the workplace. These matters are best left to those nurses and

therapists skilled in such matters. A form delineating the patient’s limitations often

appears for the doctor to complete. It is best that this form be completed by the

doctor after discussing with the case manager whether modified duty is available.

Usually, the availability of modified duty with the employer has been confirmed

by the case manager before the appointment. Often the injured worker is not aware

that a modified duty or return to work program is offered by employers whose

employees are injured on the job, and patients incorrectly inform the doctor that

there is no modified duty available. This kind of program is usually only offered to

workers who have been injured on the job and is not available for personal injury

or illness.

Allowing some patient participation in the process of returning to work

assists in alleviation of the sense of victimization noted by some injured

workers. Addressing the return-to-work issue in the beginning of treatment and

throughout treatment reinforces to the patient that their treatment and recovery

can be achieved while working in a modified duty status. Supportive reassur-

ance by the physician can make the transition to work during recovery easier

for the worker. Even in an ideal situation of excellent initial assessment and


treatment with an employer who provides graduated return-to-work activities

the injured employee can feel ostracized by their fellow employees who see

them returning to work with significant restrictions, which may place additional

burden on them.

Options to return-to-work

When the patient does not seem to progress as expected, an independent

medical examination may help clarify the issues. These independent medical

examinations can be of mixed benefit because they may be performed by a

physician who is not trained in the subspecialty and may miss subtle diagnostic

signs. Complex issues come into play because the physicians who conduct

examinations are paid by insurance companies. Patients may misrepresent their

symptoms and limitations, and the sorting out of true limitations caused by an

injury may test the system of evaluation and all those involved.

Vocational rehabilitation can be instrumental in assisting an injured worker to

return to the workplace. The primary determinants in predicting the return to work

seem to be education level and the status of disability benefits, with nonbenefi-

ciaries being much more likely to return to work [11]. The physician must

recognize that patients who are receiving workers’ compensation might have a

disproportionate disability and delayed recovery. Derebery and Tullis [12] note

that successful treatment depends on recognizing the emotional aspect of the

situation and then working with the employer, therapist, and other physicians.

Much can be gained by direct discussion with the patient, with the doctor

explaining his or her concerns about the slow progress and the doctor’s need to

see the patient return to work for his or her overall benefit.

The issue of secondary gain may be difficult for physicians fully to grasp. Few

surgeons miss work when they are ill. The surgeon may have difficulty

understanding the patient’s limitations and his or her feelings about returning

to work. Certainly, the desire to return to work depends to some degree on the

employee’s enjoyment of his or her work. One study of low back injuries found

that there was some benefit in a multidisciplinary program but that increased

physical functioning and decreased pain were not predictive of long-term work

status. The authors concluded that employment and financial factors may have a

strong influence on return-to-work outcomes [13]. Another study found that

active litigation and workers’ compensation claims during the perioperative

period after ankle fusion had a significant negative effect on outcome scores

and had an adverse effect on patients’ perceived ability to return to work [14].

Return-to-work strategies seem to be most effective when the following

elements are considered:

� Early intervention with diagnosis and active treatment plan� Early discussion and plans for return to work� Active rehabilitation in conjunction with modified duty


� Communication with the treatment team, especially with the case manager,

to help ensure the best result for all involved

More research could help determine appropriate treatment and return-to-work

guidelines. One recent study has evaluated a specific injury and the issues involved

with returning to work [15]. By better understanding the factors playing a role in

the worker’s recovery, the physician can better guide the rehabilitation effort to the

greatest benefit of all.

Key elements

1. Issues involving worker’s compensation patients are important. These

patients deserve the best medical care, including a correct diagnosis and

treatment protocols.

2. The best result for the injured worker is a return to work as soon as can

be managed.

3. The workers’ compensation system uses a treatment team to facilitate and

coordinate the medical care and to assist in bringing the patient back to work.

4. Nurse case manager

5. Physical and occupational therapy

6. Work-hardening and functional capacity evaluation

7. Modified duty status

8. Physicians who understand these issues can better serve their patients and

can avoid the complications of litigation.

Caring for injured workers is complicated by many issues. Understanding some

basic return-to-work strategies allows the orthopedic surgeon to get the worker

back to his or her occupation sooner. An open and frank discussion with all the

members of the health care team frequently during treatment facilitates this goal.

References

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Return to work after foot and ankle injury