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.

Fracture, Ankle


Related Terms

  • Ankle Fracture
  • Bimalleolar Fracture
  • Broken Ankle
  • Distal Fibular Fracture
  • Distal Tibia Fracture
  • Fracture of the Lateral Malleolus
  • Fracture of the Medial Malleolus
  • Fracture of the Posterior Malleolus
  • Lateral Malleolus Fracture
  • Malleolar Fracture
  • Medial Malleolus Fracture
  • Posterior Malleolar Fracture
  • Tibia Distal Fibular Injury
  • Trimalleolar Fracture

Differential Diagnosis

Specialists

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

Factors Influencing Duration

Factors that influence the length of disability include the individual's age, general health, severity of the fracture, concomitant ligament injury, degree of mobility, amount of weight bearing allowed, response to treatment, and job requirements. Associated fractures or injuries of the other lower limb or either upper limb may limit the individual's ability to use assistive devices for ambulation and require prolonged use of a wheelchair.

Medical Codes

ICD-9-CM:
824.0 - Closed Fracture of Medial Malleolus: Closed Fracture of Tibia Involving Ankle, Malleolus
824.1 - Open Fracture of Medial Malleolus
824.2 - Closed Fracture of Lateral Malleolus
824.3 - Open Fracture of Lateral Malleolus
824.4 - Closed Bimalleolar Fracture; Potts Fracture
824.5 - Open Bimalleolar Fracture
824.6 - Closed Trimalleolar Fracture
824.7 - Open Trimalleolar Fracture
824.8 - Closed Fracture of Ankle, Unspecified
824.9 - Open Fracture of Ankle, Unspecified

Overview

© Reed Group
An ankle fracture is a break in the far end of one of the 2 bones of the lower leg: the tibia (the inside or medial bone of the lower leg) and the fibula (the outside or lateral bone of the lower leg). Both bones end in a bony prominence (malleolus) that forms an arch on top of the talus, one of the bones of the foot. The ankle is a major weight-bearing hinge joint composed of three bones: the distal tibia, distal fibula, and talus. These 3 bones are joined together by 3 groups of ligaments that hold the ankle joint in place. The deltoid ligament is on the inside of the ankle, the lateral ligament complex is on the outside of the ankle; another group of ligaments holds the tibia and fibula together. The talus itself is usually not included in a diagnosis of ankle fracture.

Ankle fractures occur most commonly when there is a sudden twisting injury to the foot. The ankle may roll in (inversion injury) or out (eversion injury), and the force on the foot can be transmitted to the tibia and fibula, resulting in fracture. The physician will often try to ascertain exactly how the injury occurred. Knowing the position of the ankle at the time of injury can help determine the mechanism of injury, which gives important information about which bones and ligaments were probably damaged. Fractures also can occur in individuals with unstable ankle joints and a history of recurrent ankle sprains.

As with other types of fractures, ankle fractures are described as either displaced or nondisplaced. In a displaced fracture, the fractured bone segments have moved out of alignment, while in a nondisplaced ankle fracture they have not. Any type of ankle fracture can affect the joint surface and joint motion (articulation) and almost always involves concomitant ligament injuries.

The prominent malleolar surfaces on the medial and lateral sides of the ankle are the most commonly injured areas. When one of the three bony prominences is fractured, the break is referred to as an isolated malleolus fracture. A fracture involving two malleolar prominences is called a bimalleolar fracture, and fracture of both malleoli and the posterior portion of the tibia is a trimalleolar fracture.

Incidence and Prevalence: In the US, the ankle is the joint most commonly injured. About 90% of sports-related injuries are ankle sprains, and 10 to 15% are ankle fractures (Steele). The incidence in the general US population is 187 per 100,000 person-years (Iskyan). As the population ages, the incidence of ankle fractures is increasing.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals who participate in activities that potentially place excessive force on the ankle joint (e.g., skiing, snowboarding, ice skating, basketball, football, soccer, rugby) are at risk for ankle fractures. Ankle fractures commonly occur in motor vehicle accidents where the foot is braced against the floorboard. Most males experiencing ankle fractures are under age 50, while most women experiencing ankle fractures are over age 50 (Iskyan).

Source: Medical Disability Advisor



Diagnosis

History: A thorough history should be obtained including any medical conditions (especially diabetes, osteoporosis, peripheral vascular disease), medication history (corticosteroids), history of foot and ankle injuries and surgeries, and events surrounding the current injury. The individual may be able to recall the foot either turning or rolling in or out in relation to the lower leg. The ankle may be swollen, painful, and discolored. Individual may report inability to bear weight immediately after the injury and an audible popping sound may have occurred at the time of injury.

Physical exam: Observation of the lower extremity and ankle may reveal swelling, bruising (ecchymosis), deformity, and open wounds. Using the fingers to feel the ankle (palpation) can reveal focal bony tenderness and may localize the area of fracture. The presence and quality of pulses in the posterior tibial and dorsalis pedis arteries should be noted and compared with the unaffected ankle. Capillary refill time and neurological exam should be noted for both feet. Active and passive range of motion should be documented.

The physician will determine if the injury is stable or unstable; instability may include bony and ligamentous injury on both the inside and outside (medial and lateral sides) of the ankle. Unstable fractures usually require urgent orthopedic attention. The physician will also assess for joint dislocation and presence of other traumatic injuries.

Tests: Since about 90% of ankle injuries are due to strains or sprains, ankle x-rays are reserved for suspected fractures. The Ottawa ankle rules developed by Stiell and colleagues are helpful in determining which individuals should receive X-rays. Three views of the ankle are standard. A standing view can help evaluate ligamentous instability. Radiographic comparison of the injured foot with the non-injured may be helpful in some cases. Occasionally, a CT or MRI may be ordered to evaluate joint surface changes, fracture position, ligaments, and soft tissue. After the bones have been realigned in their anatomically normal position (reduction) follow-up x-rays usually are necessary.

Source: Medical Disability Advisor



Treatment

If the fracture is not displaced, treatment with cast or brace (immobilization) is usually sufficient for stable fractures. If the fracture is displaced, reduction is essential. This can be accomplished by either closed (nonsurgical) reduction or surgical reduction, internal fixation (ORIF). Stability of the fracture after reduction is critical to maintain ankle motion and prevent complications such as degenerative arthritis. Because joint stability depends on both bone position and ligament support, any injured ligaments must be treated along with the fracture to restore ankle stability. Post-reduction immobilization is necessary to maintain stability while healing occurs. Weight bearing is restricted for a period based on the type and location of the fracture, stability, and bone healing. Early mobilization of the joint while maintaining proper alignment of the bones should begin as soon as possible.

Source: Medical Disability Advisor



Prognosis

An ankle fracture that heals in perfect alignment usually leaves little or no impairment. Some individuals may be left with post-traumatic arthritis of the ankle joint, continued pain, or a tendency for recurrent ankle sprains. Fractures of the weight-bearing portion of the tibia have a more guarded prognosis, since any change in the anatomic position of the fracture fragments is likely to result in long-term post-traumatic arthritis.

Source: Medical Disability Advisor



Rehabilitation

The duration of treatment of an ankle fracture is related to the associated soft tissue involvement, location and type of fracture (Chapman). The main focus of rehabilitation should emphasize restoring full range of motion, strength, proprioception and endurance while maintaining independence in all activities of daily living (Osborne). Resumption of pre-injury status is the goal with consideration of any residual deficit. Appropriate early mobilization of the ankle joint hastens recovery; however, protocols for initial rehabilitation must be based upon stability of the fracture and fracture management (operative, nonoperative).

The goal of rehabilitation is to decrease pain and restore full function, with a painless mobile ankle. Local cold application may be beneficial for controlling pain and edema (Mora). Individuals should be encouraged to continue functional activities to prevent complications of inactivity and bed rest. Gait training using appropriate assistive devices is indicated to promote independent ambulation (Osborne). Individuals may progress from walker to crutches to cane based on ability and weight bearing status. If casted, range of motion exercises of the adjacent joints may be beneficial unless contraindicated based on fracture stability. After cast removal, range of motion, proprioceptive, and strengthening exercises should be started at the ankle (Osborne). For some cases with significant ligament damage, recovery may be more rapid with functional rehabilitation than 2 weeks of cast immobilization (Karlsson). Walking early during the immobilization period or use of a removable brace may improve ankle movement and encourage earlier return to activities. Passive movement therapy may benefit some individuals (Lin). Exercise intensity and difficulty should be progressed until full function is evident. Edema is a common problem and may be controlled using modalities such as cold packs and compressive wrapping. If operatively managed, the rehabilitation protocol will be directed by the treating physician.

Bone healing may occur within 6 to 12 weeks; however, the bone strength and the ability of the bone to sustain a heavy load may take up to 1 year. Once healing has occurred, the individual may resume full activities of daily living. It is important to instruct the individual not to overload the fracture site until the bone has regained its full strength. The resumption of heavy work and sports should be guided by the treating physician.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistFracture, Ankle
Physical TherapistUp to 20 visits within 10 weeks
Surgical
SpecialistFracture, Ankle
Physical TherapistUp to 16 visits within 8 weeks
Note on Nonsurgical Guidelines: Rehabilitation may not begin until tissue healing, about 6 to 8 weeks after the fracture.
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 can include tendon subluxation or disruption, wound infection, injury to the nerves and vessels in the area, non-union or delayed union of the fracture, ankle joint instability, degenerative arthritis, complex regional pain syndrome (CRPS), permanent loss of range of motion, and calcification of the ligaments. Delay in surgical treatment of a complex fracture or ligament injury can increase risk of complications.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Restrictions and accommodations include limited or no weight bearing for several weeks; use of crutches, canes, walker, or wheelchair; and limited standing, stair climbing, or walking. Rest periods may be necessary to allow for elevation of the foot and lower leg. Use of prescribed medications for pain control and inflammation may limit the individual's ability to drive a motor vehicle and operate heavy machinery. 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:

  • Which bone(s) were fractured?
  • Was fracture displaced or non-displaced? Was individual's ankle also dislocated?
  • Was the weight-bearing surface of the tibia fractured?
  • Has individual had routine ankle x-rays? Were standing views performed? Has individual had a CT scan or MRI?
  • Does the post-reduction x-ray show good alignment of the fracture pieces, or is part of the fracture still out of position?
  • Were any neurovascular structures compromised?

Regarding treatment:

  • If the fracture was nondisplaced, was the joint immobilized?
  • If the fracture was displaced, was closed or open reduction done? Was ORIF performed?
  • Were there other injuries? Was ankle kept non-weight bearing?

Regarding prognosis:

  • Did individual begin physical therapy at the appropriate time?
  • Is individual actively involved and complying with physical therapy and home exercise program to strengthen the ankle?
  • Does individual have any conditions that may affect ability to recover?
  • Does individual have any complications that may prolong recovery?

Source: Medical Disability Advisor



References

Cited

Bucholz, Robert, and James D. Heckman. Rockwood and Green's Fractures in Adults. 6th ed. Philadelphia: Lippincott, Williams & Wilkins, 2005.

Chapman, Michael W. Chapman's Orthopaedic Surgery. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 2001.

Iskyan, Kara, and Andrew Aronson. "Fracture, Ankle." eMedicine. Eds. Francis Counselman, et al. 15 Jul. 2008. Medscape. 12 Jan. 2009 <http://emedicine.medscape.com/article/824224-overview>.

Karlsson, J., et al., eds. "Early Mobilization Versus Immobilization after Ankle Ligament Stabilization." Scandinavian Journal of Medicine and Science in Sports 9 5 (1999): 299-303.

Lin, C. WC, A. M. Moseley, and K. M. Refshauge. "Rehabilitation for ankle fractures." Cochrane Database of Systematic Reviews 3 (2008): CD: 005595.

Mora, S., C. G. Zalavras, and David B. Thordarson. "The Role of Pulsatile Cold Compression in Edema Resolution Following Ankle Fractures: A Randomized Clinical Trial." Foot & Ankle International 23 11 (2002): 999-1002. National Center for Biotechnology Information. National Library of Medicine. 8 Oct. 2008 <PMID 12449403>.

Osborne, Michael. "Chapter 77 - Chronic Ankle Instability." Essentials of Physical Medicine and Rehabilitation. Eds. Walter R. Frontera, Julie K. Silver, and Thomas Rizzo. 2nd ed. Philadelphia: Saunders, Elsevier, 2008.

Steele, Phillip M., and John D. Kelly. "Ankle Fracture." eMedicine. Eds. David T. Bernhardt, et al. 5 Jun. 2006. Medscape. 12 Jan. 2009 <http://emedicine.com/sports/topic4.htm>.

Source: Medical Disability Advisor






Feedback
Send us comments, suggestions, corrections, or anything you would like us to hear. If you are not logged in, you must include your email address, in order for us to respond. We cannot, unfortunately, respond to every comment. If you are seeking medical advice, please contact your physician. Thank you!
Send this comment to:
Sales Customer Support Content Development
 
This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is published with the understanding that the author, editors, and publisher are not engaged in rendering medical, legal, accounting or other professional service. If medical, legal, or other expert assistance is required, the service of a competent professional should be sought. We are unable to respond to requests for advice. Any Sales inquiries should include an email address or other means of communication.