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, Calcaneus


Related Terms

  • Calcaneal Fracture
  • Calcaneus Fracture
  • Extra-Articular Calcaneus Fracture
  • Heel Fracture
  • Intra-Articular Calcaneus Fracture
  • Os Calcis

Specialists

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

Comorbid Conditions

Factors Influencing Duration

The type of fracture, involvement and amount of joint surface disruption, treatment, and amount of weight bearing required for job activities may all affect disability. Duration of disability depends on job requirements and whether job duties can be performed while seated. Heavy work is not usually compatible with intra-articular fracture of the calcaneal body. Duration of disability can be affected by age, diabetes, vascular disease and associated nerve injury. Other factors include non-union and post-traumatic arthritis.

Medical Codes

ICD-9-CM:
825.1 - Open Fracture of Calcaneus (Heel Bone)

Overview

© Reed Group
A fracture of the calcaneus is a break (fracture) of the heel (calcaneus), which is the largest bone in the foot. The calcaneus maintains and supports the lateral column of the foot and provides a stable, but accommodating, foundation for body weight. It is also important in propelling the foot forward during walking. Any of these functions can be seriously impaired by its fracture.

Calcaneus fractures can occur from high-velocity impact such as a fall from a height of 6 feet or higher or a motor vehicle accident. As a result, calcaneus fractures are often associated with other injuries, such as compression fractures of the spine or femur. Up to 10% of individuals with calcaneus fracture also sustain compression fractures of the lower (lumbar) spine (Nicklebur). A significant number of fractures of the calcaneus result in disruption of the joint surface between the calcaneus and ankle bone (talus).

Calcaneal fractures are classified by their location, either through the body of the bone or the prominence on the sides. They are further defined by the amount of disruption of the joint surface and amount of bone fragment movement away from the normal positioning (displacement). “Intra-articular” calcaneal fractures disrupt the alignment of the subtalar joint; “extra-articular” calcaneal fractures do not. Less frequently, calcaneal fracture may disrupt other joints of the foot.

Incidence and Prevalence: Calcaneus fractures account for 10% of fractures in the foot, and 1% to 2% of all fractures (Nicklebur).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals whose work involves jumping to the ground from significant heights (construction workers, warehouse workers, truck loaders, agricultural workers) are at risk for calcaneus fractures. Those who participate in sports with the potential for falling from a height, such as pole-vaulting, high-jumping, gymnastics, or skating, are also at risk.

Men are 5 times more likely than women to sustain a calcaneus fracture. Calcaneus fractures occur most frequently in individuals between the ages of 30 to 50 years, with a peak incidence at 45 years of age (Silbergleit).

Source: Medical Disability Advisor



Diagnosis

History: A complete medical history is obtained, including prior fractures or orthopedic surgery, underlying medical conditions (especially bone disease, neoplasia, arthritis), medications taken, allergies, and occupation. A description of the mechanism of injury, including the magnitude, location, and direction of impact, is helpful. Individuals may report a traumatic event such as a fall or jump onto the heel. There may be pain, swelling, and discoloration around the foot and ankle. Individuals are often unable to bear weight on the injured foot. Individuals may complain of back or thigh pain if there has been concomitant compression fracture of the spine or femur.

Physical exam: Observation of the ankle may reveal deformity of the foot, heel, or plantar arch. Deformity of the hindfoot, such as shortening, widening, or crookedness (angulation), is common. Swelling (edema) and / or a pattern of bruising (ecchymosis) that tracks along the outside (distal) of the foot to the sole (Mondor sign) may be present. An open wound may be present, especially if the injury was sustained during a motor vehicle accident. Holding the heel and gently squeezing it (palpation) elicits pain over the calcaneal protuberances (tuberosities) or the hindfoot. A thorough neurovascular examination is essential. Ankle range of motion is often diminished, with pain at the extremes of motion. The individual may have difficulty pointing the toe downward (plantar flexion) with a fracture to the rear (posterior) tuberosity. With impaction fractures, there may be deformity in the Achilles tendon area and ecchymosis along the sole of the foot. Examination of both feet, ankles, and knees, as well as the spine, is necessary to rule out any associated injuries.

Tests: Multiple angle plain x-rays are ordered first, followed by CT and MRI scan to evaluate joint surface integrity and position of fracture fragments. The advent of CT has made it possible to accurately diagnose, treat, and determine the prognosis for calcaneal fractures. A complete blood count (CBC), blood typing, coagulation profiles, and electrocardiogram (ECG) are part of routine preparation for surgery. The necessity of other laboratory studies depends on the extent of injury and comorbid conditions.

Source: Medical Disability Advisor



Treatment

Definitive treatment of calcaneus fractures may be deferred for several days to allow soft tissue swelling and injuries to resolve. In these cases, initial treatment consists of rest, ice, compression, and elevation (RICE). A short leg posterior plaster splint may be applied.

Most fractures that are not displaced and do not involve the joint (extra-articular fractures) are treated nonoperatively if the injury does not alter hindfoot biomechanics or change weight bearing. Comminuted (many pieces) intra-articular fractures with little chance for a successful outcome on reconstruction are also managed nonoperatively. Nonoperative treatment requires an experienced orthopedic surgeon and close coordination with a physical therapist and an orthotist. A short leg cast is applied with no weight bearing for 2 weeks, and then individual may begin range of motion exercises. Progressive weight bearing begins at 8 weeks, and full weight bearing is expected at 12 weeks.

The treatment of open fractures begins with thorough irrigation under pressure, followed by surgical removal of dead tissue (open débridement). Unstable and / or displaced fractures are treated surgically (open reduction and internal fixation, or ORIF) using screws and / or plates to stabilize the bone fragments. ORIF is complicated by the regional anatomy, type of bone, and the high frequency of infection. A bone graft may be necessary to compensate for bone lost during crushing injuries.

Fractures associated with significant soft tissue damage may be treated by closed reduction in which the stabilizing screws or pins are inserted through the skin (percutaneous osteosynthesis). As an alternative, external fixators are sometimes used. These procedures are usually performed within 48 hours of injury. Medications include analgesics for pain, and antibiotics and a tetanus shot (tetanus prophylaxis) for open fractures.

Source: Medical Disability Advisor



Prognosis

Conservative treatment of the 25% of calcaneal fractures that do not involve the joint surface and are not displaced usually results in a positive outcome (Nicklebur). Intra-articular fractures have a poorer long-term prognosis than extra-articular fractures. If the calcaneus heals with significant deformity (widening) and if the fracture involves the subtalar joint, the individual is more likely to experience chronic pain and stiffness. Realigning (reducing) the subtalar joint and thus restoring the heel to its original position improves the long-term prognosis. Early heel joint motion is critical for the restoration of function.

Recent studies of operative treatment (open reduction) for displaced calcaneal fractures reveal a good to excellent outcome in 70% to 80% of cases (Murphy). The success rate decreases as the number of bone fragments increases. The failure rate for operative treatment of fractures in which the calcaneus is broken into many small pieces (comminuted fracture) has been reported to be as high as 73% (Murphy).

Source: Medical Disability Advisor



Rehabilitation

The duration of treatment for a fracture of the calcaneus is related to the associated soft tissue involvement and type of fracture. 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 (Bucholz). Resumption of pre-injury status is the goal with consideration of any residual deficit. Protocols for rehabilitation must be based upon stability of the fracture and fracture management (operative, nonoperative).

The goal of rehabilitation with a calcaneus fracture is to return the patient to full function with a painless mobile ankle, when possible. Swelling (edema) is a common problem and may be controlled using modalities such as cold packs and compressive wrapping. Control of edema is especially important prior to any surgical procedures, and may take up to 2 to 3 weeks to achieve. The individual should be encouraged to continue functional activities to prevent complications of inactivity and bed rest. Gait training using appropriate assistive devices is indicated based on ability and weight-bearing status. If casted, the individual may benefit from range of motion exercises of the adjacent joints, unless this is contraindicated based on fracture stability (Easley). After cast removal, the individual begins range of motion, proprioceptive, and strengthening exercises, which should be progressed until full function is evident.

If operatively managed, the protocol for rehabilitation will be dictated by the treating physician. In some cases a subtalar fusion may be performed, which can lead to an earlier return to work.

Bone healing may occur within 10 to 12 weeks; however, weight bearing is usually not permitted until there is bone union. Return to demanding job duties may take up to 4 to 6 months and may not occur in some cases. The bone strength and the ability of the bone to sustain a heavy load may take up to several years (Chapman). 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, Calcaneus
Physical TherapistUp to 20 visits within 12 weeks
Surgical
SpecialistFracture, Calcaneus
Physical TherapistUp to 20 visits within 12 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

Pressure from swelling or bleeding can result in compartment syndrome, which can cause permanent muscle and nerve damage. Nerve entrapment and peroneal tendon dislocation or entrapment can occur with the fracture. Degenerative arthritis and chronic pain are complications of calcaneal fracture. With displaced fractures, the bone fragments may not align correctly (malunion) or may fail to join (nonunion). Injuries to the foot can cause the toes to stiffen into nonfunctional positions (contractures). A decreased blood supply can lead to tissue breakdown (avascular necrosis).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work restrictions and accommodations may include no weight bearing for 6 to 8 weeks, along with use of crutches, walker, or wheelchair. An individual will not be able to climb stairs and ladders, stand, walk, drive a motor vehicle, or operate heavy equipment until the fracture has healed completely. The ability to maneuver in small or congested areas may also be affected. Frequent rest periods with elevation of the affected leg may be necessary.

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:

  • Has diagnosis of fracture of the calcaneus been confirmed?
  • Has individual experienced any complications?
  • Have plain x-rays been taken during the recovery phase?
  • Was individual diagnosed with compartment syndrome?
  • Does individual experience heel pain during or after physical activity?

Regarding treatment:

  • Have complications occurred?
  • What treatment options are now being considered?
  • Was displaced fracture managed soon after the injury occurred?
  • Was surgery performed? What type? When?
  • Was individual compliant with physical therapy and a home exercise program?
  • Did individual engage in weight bearing too soon?
  • Does individual smoke? Does individual have poor blood circulation to the legs?

Regarding prognosis:

  • Has nonunion or malunion occurred?
  • How severe are the symptoms? Are they incapacitating?
  • Can individual walk with use of a cane or crutches?
  • Can individual’s employer provide accommodations needed for full recovery?
  • Can individual perform the normal activities of daily life?

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.

Digiovanni, B., et al. "Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up." Journal of Bone and Joint Surgery 88 8 (2006): 1775-1781.

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.

Nicklebur, Scott, et al. "Calcaneus Fractures." eMedicine. Eds. James K. DeOrio, et al. 9 Jun. 2008. Medscape. 16 Mar. 2009 <http://emedicine.medscape.com/article/1232246-overview>.

Rahul, Banerjee, et al. "Chapter 61 - Foot Injuries." Skeletal Trauma. Eds. Bruce D. Browner, et al. 4 ed. Saunders, 2008.

Silbergleit, Robert. "Fracture, Foot." eMedicine. Eds. Francis Counselman, et al. 6 Feb. 2009. Medscape. 17 Mar. 2009 <http://emedicine.medscape.com/article/825060-overview>.

Source: Medical Disability Advisor






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