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.

Excision, Fusion, and Repair of Toes


Related Terms

  • Amputation
  • Arthrodesis
  • Phalangectomy

Specialists

  • General Surgeon
  • Orthopedic (Orthopaedic) Surgeon
  • Physical Therapist
  • Podiatrist

Comorbid Conditions

Factors Influencing Duration

The original diagnosis, surgical technique used, and any postoperative complications will influence the length of disability.

Medical Codes

ICD-9-CM:
77.51 - Bunionectomy with Soft Tissue Correction and Osteotomy of the First Metatarsal
77.52 - Bunionectomy with Soft Tissue Correction and Arthrodesis
77.53 - Other Bunionectomy with Soft Tissue Correction
77.54 - Excision or Correction of Bunionette; That with Osteotomy
77.56 - Repair of Hammer Toe; Filleting of Hammer Toe; Fusion of Hammer Toe; Phalangectomy (Partial) of Hammer Toe
77.57 - Repair of Claw Toe; Fusion of Claw Toe; Phalangectomy (Partial) of Claw Toe; Capsulotomy of Claw Toe; Tendon Lengthening of Claw Toe
77.58 - Other Excision, Fusion, and Repair of Toes; Cockup Toe Repair; Overlapping Toe Repair; That with use of Prosthetic Materials
77.59 - Other Bunionectomy; Resection of Hallux Valgus Joint with Insertion of Prosthesis
81.15 - Tarsometatarsal Fusion

Overview

Excision, or amputation, of a toe refers to the surgical removal of a toe or a portion of a toe (e.g., distal phalanx). Fusion (arthrodesis) of a toe refers to the permanent fusing and immobilization of a joint or joints in a toe. Repair of a toe refers to the correcting or curing of a condition or disease in that toe.

Source: Medical Disability Advisor



Reason for Procedure

The general indications for toe amputation are similar to those for any amputation (infection, gangrene), but specific indications for toe amputation exist as well. The fifth or baby toe is the most commonly amputated toe. It is usually removed for crowding, or overriding, the fourth toe. Other reasons for amputation include severe injury and tumor.

Fusion is indicated for great toe deformities, such as hallux valgus, as well as failed bunionectomy, degenerative joint disease, rheumatoid arthritis, or severe deformity.

Repair procedures are performed for lesser toe deformities such as hammertoe, mallet toe, claw toes, curly toes, or overlapping fifth toe.

Source: Medical Disability Advisor



How Procedure is Performed

During excision, or amputation, the surgeon makes a cut in the skin of the toe. After the major blood vessels are tied off, minor blood vessels are cauterized, and a flap of skin is prepared, the toe is cut off. The flap of skin is then sewn closed to cover the wound. A temporary drain may be left in the incision to allow blood and fluid to drain.

In arthrodesis of a metatarsophalangeal joint, an incision is made over the joint, and capsule tissues are stripped from both over and under the joint (dorsal and plantar surfaces) so that the joint is widely exposed. Bony growth from the surface of the bone (exostosis) is then excised and saved to provide a source of bone for grafting, and a large towel clip is used to help hold the joint steady. After cartilage from the metatarsal bone and from the toe itself (phalanx) is removed, the metatarsal bone is shaped into a rounded cone, and the base of the toe itself (proximal phalangeal base) is shaped into a rounded cup. Wires and/or screws are placed to secure the joint. Intra-operative radiographs (or fluoroscopy) are used to examine for areas of partial bone separation; any areas of bone separation should be filled in with bone graft from the exostosis. The incision is then closed. The individual's foot will be placed in a non-weight-bearing cast for about 6 weeks, depending on progress as measured by radiographic results. Once the fused bones have matured, the individual may find footwear somewhat limited, especially with regard to heel height. In some cases, individuals may prefer a rocker-bottom type of sole.

The procedures to repair toe deformities involve cutting or lengthening tendons, trimming or resecting a metatarsal head, releasing soft tissue, or a combination of these procedures. There are numerous repair procedures for various toe conditions, including the frequently used ones described below.

Hammertoes and claw toes (toes with flexion deformities) can be treated with a procedure called a flexor-extensor transfer. Under intravenous (IV) sedation and a local block, a small longitudinal incision is made over the bottom (plantar) surface of the metacarpal head/neck region of the affected toe. The flexor digitorum longus (FDL) tendon that normally flexes a toe (allows it to curl downward) is transferred to the extensor side of the toe, so that it can help straighten or extend the toe. The wounds are then closed with stitches and dressed.

An overlapping fifth toe can be treated with a procedure called Butler's surgical correction. An incision is made over the top of the little toe (digit), centered over the extensor digitorum longus (EDL) tendon, which will allow the toe to later be turned (derotated) to its normal position. A second incision is made on the underside (plantar aspect) of the toe and brought laterally and proximally, allowing the toe to be moved to the side (laterally) and down. The contracted EDL tendon and the dorsal capsule are then released. For a positive surgical result, the toe must lie passively in a corrected position; forced correction may place tension on the toe's blood vessels. Skin sutures will help keep the toe in a derotated position.

Source: Medical Disability Advisor



Prognosis

Toe amputation usually yields good results in the general population, allowing individuals to return to most normal activities. However, in the diabetic population, toe amputation can lead to future ulcerations if the blood supply to the amputation site is inadequate for wound healing to occur.

Fusion (arthrodesis) may alleviate pain, but it leaves the individual with a joint that can no longer move. This may make walking more difficult, and a rocker-sole shoe may be used to improve the gait following a fusion procedure.

The repair procedures described normally yield good results, allowing individuals to return to most normal activities.

Source: Medical Disability Advisor



Rehabilitation

The primary goal of rehabilitation for individuals who undergo excision, fusion, or repair of toes is the control of pain and swelling and gait training. This can be accomplished through the use of modalities such as heat or cold for pain management (Braddom) and assistive devices such as canes or walkers to limit the weight borne by the feet. The second goal of physical therapy is to increase the flexibility of the uninvolved structures adjacent to the involved area, and, once healing has occurred, to the entire foot and ankle. The third goal of physical therapy is strengthening the foot and ankle. It can be achieved by strengthening the intrinsic and extrinsic muscles of the foot and ankle.

The final goal of physical therapy is regaining functional abilities. Therapists focus on normalizing an individual's gait pattern and balance responses once full-weight bearing through the foot is permitted. Orthotics may be required for some patients. (Simons).

Additional information may provide insight into the rehabilitation needs of these individuals (Lau).

FREQUENCY OF REHABILITATION VISITS
Surgical
SpecialistExcision, Fusion, and Repair of Toes
Physical TherapistUp to 8 visits within 4 weeks
Note on Surgical Guidelines: Rehabilitation may be initiated, halted to allow for healing, and then resumed.
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

Complications of a toe excision (amputation) may include postoperative infection, blood clots, and gait changes. The surgical wound may fail to heal, especially in individuals with diabetes or peripheral vascular disease. This may lead to additional, more proximal amputations. The individual's gait may not be affected by amputation of the fifth toe. However, amputation of the great toe can have a marked impact on gait, particularly running. Deformity of the great toe, specifically hallux valgus, is a common complication of second toe amputations. Fusion and repair procedures may result in persistent localized swelling that generally resolves with time (Beaty; Mann). Injury to adjacent nerves may result in areas of numbness around the surgical site. Other complications of toe arthrodesis (fusion) may include infection, blood clots, malunion, or nonunion. If a metatarsophalangeal fusion procedure results in the toe bending upward excessively (excessive dorsiflexion), the interphalangeal (IP) joint may begin to rub in the shoe, causing the toe to claw and consequently limiting the type of footwear the individual can wear. All the repair procedures may be complicated by postoperative infection and blood clots.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Accommodations and restrictions are intended to protect repaired toes or surgical sites until adequate healing has occurred. Appropriately fitted and supportive footwear is necessary to sustain and maintain a recovery for return to work. Standing and walking may need to be temporarily limited. A short leg cast or postsurgical shoe may be necessary; crutches or a cane may need to be used for a short time postoperatively. Climbing, stooping, and squatting may need to be temporarily eliminated. Accommodation for the individual to keep the foot elevated may be necessary.

Source: Medical Disability Advisor



References

Cited

Beaty, J. H. "Congenital Anomalies of the Lower Extremity." Campbell's Operative Orthopaedics. Eds. S. Terry Canale and James H. Beaty. 11th ed. Philadelphia: Mosby Elsevier, 2008.

Braddom, Randolph L. Physical Medicine and Rehabilitation. 3rd ed. Philadelphia: W.B. Saunders, 2006.

Lau, J. T., and T. R. Daniels. "Outcomes Following Cheilectomy and Interpositional Arthroplasty in Hallux Rigidus." Foot & Ankle International 22 6 (2001): 462-470. National Center for Biotechnology Information. National Library of Medicine. 29 Nov. 2004 <PMID: 11475452>.

Mann, Roger A. "Foot and Ankle." Orthopaedic Sports Medicine. Eds. Jesse DeLee and David Drez. Philadelphia: Saunders Elsevier, 2003.

Simons, Stephen, and Robert Kennedy. "Chapter 34 - Foot Injuries." Clinical Sports Medicine: Medical Management and Rehabilitation. Eds. Walter R. Frontera, et al. 1st ed. W.B. Saunders, 2006.

General

DeOrio, James K. "Claw Toe." eMedicine. Eds. John S. Early, et al. 2 2008. Medscape. 5 Jan. 2009 <http://emedicine.com/orthoped/topic51.htm>.

Schroeder, Stephen A., et al. "Fifth-toe Deformities." eMedicine. Eds. John S. Early, et al. 19 Dec. 2008. Medscape. 5 Jan. 2009 <http://emedicine.com/orthoped/topic388.htm>.

Watson, Anthony. "Hammertoe Deformity." eMedicine. Eds. Heidi M. Stephens, et al. 15 Mar. 2007. Medscape. 5 Jan. 2009 <http://emedicine.com/orthoped/topic457.htm>.

Source: Medical Disability Advisor






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