Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Dislocation, Foot

dislocation, foot in français (France)

Related Terms

  • Disarticulation
  • Displacement
  • Interphalangeal Joint Dislocation
  • Lisfranc dislocation
  • Luxation
  • Metatarsophalangeal Joint Dislocation

Differential Diagnosis

Specialists

  • Emergency Medicine Physician
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist

Comorbid Conditions

Factors Influencing Duration

Length of disability is influenced by the severity of symptoms, a coexisting foot injury, underlying joint disease, chronic illness, type and outcome of treatment, appropriate participation in physical therapy and home exercise program, and the job and lifestyle requirements of the individual. For dislocation of the tarsometatarsal joint, duration for sedentary and light work reflects work in a cast or brace.

Medical Codes

ICD-9-CM:
838.00 - Dislocation of Foot, Closed, Unspecified
838.01 - Dislocation of Foot, Closed, Tarsal (Bone), Joint Unspecified
838.02 - Dislocation of Foot, Closed, Midtarsal (Joint)
838.03 - Dislocation of Foot, Closed, Tarsometatarsal (Joint)
838.04 - Dislocation of Foot, Closed, Metatarsal (Bone), Joint Unspecified
838.05 - Dislocation of Foot, Closed, Metatarsophalangeal (Joint)
838.06 - Dislocation of Foot, Closed, Interphalangeal (Joint) of Foot
838.09 - Dislocation of Foot, Closed, Other Part; Toe(s), Phalanx of Foot
838.10 - Dislocation of Foot, Open, Unspecified
838.11 - Dislocation of Foot, Open, Tarsal (Bone), Joint Unspecified
838.12 - Dislocation of Foot, Open, Midtarsal (Joint)
838.13 - Dislocation of Foot, Open, Tarsometatarsal (Joint)
838.14 - Dislocation of Foot, Open, Metatarsal (Bone), Joint Unspecified
838.15 - Dislocation of Foot, Open, Metatarsophalangeal (Joint)
838.16 - Dislocation of Foot, Open, Interphalangeal (Joint) of Foot
838.19 - Dislocation of Foot, Open, Other Part; Toe(s), Phalanx of Foot

Overview

© Reed Group
Dislocation of the foot is an uncommon injury that usually occurs in individuals sustaining multiple trauma such as from a motor vehicle accident. The foot can be divided into three sections: forefoot, midfoot, and hindfoot. The forefoot consists of 19 bones (phalanges and metatarsals) that make up the 5 toes. The midfoot is composed of the navicular, cuboid, and 3 cuneiform bones. The hindfoot is made up of the talus and calcaneus bones. Dislocations usually involve the talus, the tarsometatarsal joints (Lisfranc dislocation), or the toes (metatarsophalangeal [MTP] and interphalangeal [IP] joints).

A severe injury (third-degree sprain) to any ligaments in the foot can result in joint dislocation because when ligaments cannot absorb stress, they tear. Joint dislocations (luxations) result in complete separation of the surface of the joint accompanied by severe ligament and joint capsule damage. In a partial dislocation (subluxation), a portion of the joint surface remains intact and the supporting ligaments are stretched but not completely torn. Joint displacement can result from a direct crushing force, twisting of the foot, or direct impact. Landing in an abnormal position on the foot also can cause a dislocation(s). The direction of the force on the foot determines the direction of the dislocation(s). Many foot dislocations are accompanied by fractures.

Stubbing the toe is a common cause of dislocation of the forefoot, displacing the joint of the toe (interphalangeal joint). The most common complete dislocation of the foot also occurs in the forefoot where the toes join the metatarsal bones (metatarsophalangeal joint). This dislocation requires immediate treatment to realign the bones of the joint to their normal position (reduction).

The midfoot contains the navicular, cuboid, and cuneiform bones and the intertarsal joints. Dislocations in this area often are caused by crushing blows to the top of the foot or when the individual experiences a fall. They can be difficult to diagnose and manage because of associated fractures, swelling, and subtle x-ray findings. Between the midfoot and the forefoot is the Lisfranc joint complex, which is comprised of the 5 tarsometatarsal joint articulations. Dislocation of this complex occurs most often as a result of sport injuries or motor vehicle accidents.

The joints of the hindfoot (talocalcaneal and subtalar joints, respectively) are susceptible to injuries from jumps, falls, motor vehicle accidents, and during contact and kicking sports. Dislocation of the hindfoot is often associated with fractures. Concomitant damage to blood vessels, nerves, or tendons can lead to complications that compromise circulation and foot function. If the dislocation is not properly reduced, vascular compromise may result in loss of blood supply to the foot (avascular necrosis) and subsequent death of tissue (ischemia), a complication that can lead to gangrene and ultimately, amputation.

Foot dislocation also may be caused by Charcot foot, which is the disintegration of ligaments and joint surfaces secondary to disease or injury. This most frequently affects the tarsals and metatarsals and is commonly associated with diabetes mellitus.

Incidence and Prevalence: Dislocation of the foot is a rare injury; it is thought to account for fewer than 1% of all dislocations in the US (McStay). One French study, however, found that hindfoot dislocations involving the talocalcaneal and subtalar joints represented nearly 1% of all dislocations (Maes).

Dislocations of the Lisfranc joint complex are the most common type of foot dislocation, and are estimated to occur with an incidence of 1 in 50,000 dislocations per year (McStay). In one study of individuals with midfoot fractures following traumatic injury, over 31% of these also sustained a Lisfranc joint dislocation (Richter).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Foot dislocation can occur at any age, but males are 6 times more likely to experience a foot dislocation than females (McStay). This is most likely a result of greater participation of young males in high-impact sports and also their increased rate of involvement in motor vehicle accidents, both of which lead to more severe dislocations injuries.

Of individuals with diabetes mellitus, 60% to 70% will develop peripheral nerve damage. Of these, about 0.5% will develop Charcot foot, a risk factor for foot dislocation ("Charcot Foot"). Charcot foot is most likely to occur in older individuals who have had diabetes for 15 to 20 years.

Source: Medical Disability Advisor



Diagnosis

History: A thorough medical history is essential and should include underlying medical conditions, current medications, prior foot injuries, and surgeries. A detailed description of events leading up to the accident will help establish the mechanism of injury. This information is crucial since it can guide the physician to the specific type of dislocation. The individual may report a history of recent traumatic injury and complain of pain, swelling, decreased activity, and / or difficulty with bearing weight on the foot. Depending on the severity and type of dislocation(s), the individual may report a change in appearance of the foot.

Physical exam: The exam may reveal localized pain when light pressure is applied with the fingers (palpation) over the joint(s) involved. Localized swelling and deformity of the area may also occur. Elevation and stretching (tenting) of the skin over the involved joint is often noted. If multiple joints or areas of the foot are involved, pain, swelling, and deformity may be more general over the foot. Decreased circulation and sensation (neurovascular compromise) may also be present. A detailed neurovascular examination should be conducted before and after any attempt to reduce the dislocation. Bruising (ecchymosis) may appear rapidly if blood vessels have been damaged.

Tests: Routine 3-view x-rays of the foot usually are the initial imaging study. Weight-bearing views can help reveal more subtle abnormalities common to Lisfranc fracture-dislocations. CT scan can identify bony abnormalities, while MRI is preferred for evaluation of soft tissues, tendons, and ligaments. Depending on the findings of the neurovascular examination, further studies of these systems may be required including Doppler venous testing and nerve conduction studies.

Source: Medical Disability Advisor



Treatment

Reduction of the dislocation under anesthesia (local, regional, or general) is required. This may be closed reduction (nonsurgical) or open (surgical) reduction. Subtalar dislocations are routinely treated non-surgically. Medial subtalar dislocations without fracture usually are reduced by closed methods. Reduction of dislocation in the hind and midfoot must be done promptly because of possible compromised circulation to the foot. Many dislocations are not stable after reduction and require open reduction internal fixation (ORIF), a surgical procedure that realigns the bones and reconstructs the ligaments using pins, screws, or wires.

Dislocations of the hindfoot are often open or compound injuries that require management of the wounds as well. Dislocations with associated fractures most often require ORIF to regain joint stability.

Source: Medical Disability Advisor



Prognosis

Dislocations of the toe and forefoot usually have a good outcome with proper management and compliance with treatment. Midfoot and hindfoot dislocations have a much higher risk of complications and a less favorable outcome. The best indicator of positive outcome is for the dislocated joint to return to correct anatomic alignment.

In individuals requiring surgical repair (ORIF) of the joint(s), the outcome is somewhat more guarded due to greater risk for complications. These individuals have often sustained more severe injuries.

Individuals who experience fracture with dislocation may require ORIF. The expected outcome is good, but the treatment and recovery phases will be longer than in dislocations without fracture. The possibility for infection and other complications increases with this procedure.

Source: Medical Disability Advisor



Rehabilitation

The primary focus of rehabilitation for a dislocated foot is to relieve pain and to restore pre-injury functional status. Rehabilitation is important to regain joint stability following a foot dislocation and involves exercises for strength, endurance, and proprioception. As there are several joints within the foot, the involved joint(s) and whether surgery or casting is required will determine the treatment necessary (Murphy).

Subtalar dislocations may require at least 6 weeks of casting. Dislocations involving the tarso-metatarsal joint frequently need prolonged casting, with 6 weeks of non-weight bearing followed by an additional 6 weeks of weight bearing while casted. Therapy in these cases, as well as those requiring surgery, is determined by the treating physician (Murphy).

For individuals with less complicated conditions, therapy should follow the PRICE principle (protection, rest, ice, compression, elevation) for the first 48 to 72 hours. The rehabilitation specialist may instruct the individual in the use of assistive devices such as crutches to promote independent ambulation. Modalities such as heat and ice can be used throughout rehabilitation to control pain and swelling. Individuals should be encouraged to maintain mobility and strength of the adjacent joints; range of motion and strengthening exercises can be taught if indicated.

Once pain and swelling are controlled, individuals can begin with gentle range of motion exercises of the involved foot and progress as indicated. When full pain-free range of motion is achieved, strengthening exercises are started. The physical therapist should focus on stretching and strengthening the intrinsic and extrinsic muscles of the foot and instructing individuals in a home exercise program to complement supervised rehabilitation.

The individual can progress to more advanced proprioceptive and balance exercises when indicated. The timing for this may vary based on the degree of stability of the involved joint(s) (Dhillon).

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistDislocation, Foot
Physical TherapistUp to 20 visits within 12 weeks
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Trauma to the foot may exacerbate an underlying condition such as rheumatoid arthritis, degenerative osteoarthritis, or gout. Individuals with diabetes mellitus are at high risk for foot complications. Diseases that affect the integrity of ligament tissue (such as Ehlers-Danlos syndrome) and the joint structure will complicate treatment.

Fractures, open wounds, and lacerations of tendons and blood vessels from the dislocation may complicate treatment. Infection, loss of blood supply to the surrounding tissue and bones (avascular necrosis, most commonly affecting the talus), instability of the joint, damage to the skin, nerve injury, stiffness, degenerative arthritis, and loss of the foot arch are possible complications of the injury and / or treatment.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

The location and treatment of the dislocation may require restrictions for a few weeks to months. The use of surgical shoes or casts in combination with crutches or canes is common; however, some activities may be limited (e.g., stair climbing, standing for long periods, and walking long distances). Use of hands while standing and manual dexterity can be affected when crutches or canes are needed, and lifting or carrying may not be possible or may be limited to light objects that can be carried in one hand. The foot may need to be elevated throughout the day to relieve pain and swelling.

Depending on the type of work, access to an elevator may be necessary. Modified duty, a temporary change of duties, a designated person to assist the individual as needed for certain job tasks, an area where the individual may rest and elevate the foot several times a day, and time off from work for physical therapy treatments and medical visits may be needed. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • What was the mechanism of injury?
  • Has the diagnosis been clearly established?
  • Did individual complain of pain and swelling? Difficulty walking?
  • Did the foot appear distorted?
  • Was pain present on palpation of joint(s) involved?
  • Was tenting of the skin observed over the affected joint?
  • Was neurovascular compromise identified?
  • Has individual had plain x-rays, weight-bearing x-rays, CT scan, or MRI?
  • Were fractures found on x-ray?
  • Were Doppler venous tests done if vascular injury was suspected? Nerve conduction studies?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • Was dislocation reduced under anesthesia?
  • Was ORIF required?
  • Were any additional injuries treated?
  • Did individual require rehabilitation?

Regarding prognosis:

  • Is the joint stable?
  • Is individual actively engaged in physical therapy?
  • Is individual compliant with supervised and / or home therapy?
  • Is individual's employer able to accommodate the necessary restrictions?
  • Does individual have any conditions that may affect the ability to recover?
  • Did the injury exacerbate an underlying condition?
  • Does individual have diabetes?
  • Were any tendons or blood vessels lacerated?

Source: Medical Disability Advisor



References

Cited

"Charcot Foot." Podiatry Channel. 22 May. 2007. 12 Jan. 2009 <http://www.podiatrychannel.com/charcotfoot/>.

Dhillon, M. S., and O. N. Nagi. "Total Dislocations of the Navicular: Are They Ever Isolated Injuries?" Journal of Bone and Joint Surgery 81 5 (1999): 881-885. National Center for Biotechnology Information. National Library of Medicine. 13 Sep. 2008 <PMID: 10530855>.

Maes, R., C. Averous, and G. Copin. "Lateral Peritalar Luxation: Prognostic Evaluation and Therapeutic Approach. Review of the Literature Based on a Clinical Case." Revue médicale de Bruxelles 24 6 (2003): 458-463. National Center for Biotechnology Information. National Library of Medicine. 6 Jan. 2009 <http://www.ncbi.nlm.nih.gov/entrez/query.fcgi>.

McStay, Christopher M., and Martin J. Carey. "Dislocations, Foot." eMedicine. Eds. James E. Keany, et al. 27 May. 2008. Medscape. 12 Jan. 2009 <http://emedicine.com/emerg/topic141.htm>.

Richter, M., et al. "Fractures and Fracture Dislocations of the Midfoot: Occurrence, Causes and Long-term Results." Foot & Ankle International 22 5 (2001): 392-398. National Center for Biotechnology Information. National Library of Medicine. 6 Jan. 2009 <http://www.ncbi.nlm.nih.gov/entrez/query.fcgi>.

General

Murphy, G. Andrew. "Fractures and Dislocations of the Foot." Campbell's Operative Orthopaedics. Eds. S. Terry Canale and James H. Beaty. 11th ed. Philadelphia: Mosby Elsevier, 2008.

Source: Medical Disability Advisor






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