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, Forefoot (Sesamoid, Phalanges)


Related Terms

  • Broken Foot
  • Broken Toe

Differential Diagnosis

Specialists

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

Factors Influencing Duration

Type and severity of fracture, job requirements, age of individual, complications of the injury, ability to modify work activities, and rate of healing may affect disability periods. For toe fractures, duration may depend on which digit is involved.

Medical Codes

ICD-9-CM:
825.20 - Unspecified bone(s) of Foot [except Toes]; Instep
826 - Fracture of Phalanges of Foot, One or More
826.0 - Closed Fracture of Phalanges of Foot, One or More
826.1 - Open Fracture of Phalanges of Foot, One or More

Overview

© Reed Group
A fracture of the forefoot is a break in one of the sesamoid bones or one of the phalanges. The term phalanges refers to the bones of a toe (or finger). The foot contains 14 phalanges. Each individual bone in a toe is called a phalanx. The sesamoid bones in the toes are embedded in a flexor tendon located underneath the big (great) toe or first metatarsal bone of the foot. Sesamoid fractures are uncommon; however they can be acutely injured from a fall or direct trauma. They also can be injured from repetitive overwork or stress (stress fracture). The medial sesamoid bone is more commonly involved than the lateral sesamoid.

Broken phalanges usually result from direct trauma. The great toe is the most frequently broken toe. Individuals with osteoporosis are at greater risk for fractures.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Ballet dancers and distance runners are at increased risk for sesamoid fractures, generally from repeated stress and excessive pressure on that area of the foot.

Source: Medical Disability Advisor



Diagnosis

History: When a toe is fractured, the individual may complain of pain and tenderness over the fracture site and may recall an injury to the area. The individual also may complain of increased pain upon walking or weight bearing. Sesamoid fractures produce similar symptoms over the base of the great toe. A prolonged history of pain may be indicative of a stress fracture.

Physical exam: Examination of a toe fracture may reveal swelling (edema), bruising (ecchymosis), numbness, or tingling (paresthesia) of the toe. If the bone(s) have moved out of normal alignment (displaced fracture), the toe may appear misshapen or deformed. Side-by-side comparison with the uninjured (contralateral) foot may aid in examination. Further examination of a sesamoid fracture will elicit pain upon pressing (palpating) the area of the sesamoids.

Tests: Routine x-rays (anteroposterior and oblique views) will reveal fractures of the phalanges, along with any displacement. X-rays (lateral and medial oblique sesamoid views) are obtained to confirm sesamoid fractures. Dislocations may be subtle, and comparison views of the contralateral foot may be necessary. Follow-up x-rays may be taken after the bones are returned to their normal anatomical alignment (reduced). X-rays of stress fractures often initially are negative, with radiographic changes only visible several weeks later. Bone scan, CT scan, and MRI scan be necessary to rule out other sources of pain such as sesamoiditis or infection (Goulart).

Source: Medical Disability Advisor



Treatment

Nondisplaced fractures of the phalanges may be treated with "buddy taping." This requires padding and taping the toes together for support and to limit joint motion. Elevation of the foot is an important part of the treatment. Open-toed, semi-rigid shoes usually are most comfortable. A fracture brace or a walking cast with a toe-plate may be used. Crutches may be necessary, as weight bearing may be greatly limited early in treatment. Displaced fractures and dislocations often require reduction under local anesthesia. If the fracture is unstable, open reduction internal fixation (ORIF) may be used, especially in the great toe. Elevation is recommended to reduce swelling. Treatment of these fractures usually includes a walking boot or cast and crutches, with protected weight bearing for 3 to 4 weeks.

Fractures of the sesamoid are treated with rest, nonsteroidal anti-inflammatory drugs (NSAIDs), protective padding, a semi-rigid-soled shoe, and arch supports to relieve tension in the flexor hallucis brevis and longus tendons. Weight bearing may be limited for a few days to weeks. If symptoms persist for 6 months after a sesamoid fracture, are unrelieved by corticosteroid injections, and cause functional disability, the sesamoid may be surgically removed (excised).

Source: Medical Disability Advisor



ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
 
Ankle and Foot Disorders
 
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines



Prognosis

Nondisplaced, uncomplicated fractures can be expected to heal in 6 to 8 weeks without residual damage. During that time, the ability to walk may be severely limited. Recovery from fractures that require reduction and fixation may take several weeks, as may recovery from associated soft tissue damage. Complications of the injury will extend the recovery period and may have a less successful outcome.

Following conservative treatment of a sesamoid fracture, individuals may begin to resume bearing weight. Stiff-soled shoes should be worn until pain is gone. Following a sesamoid fracture, dancers and athletes may require a full year for complete recovery.

Source: Medical Disability Advisor



Rehabilitation

Toe and sesamoid fractures typically should not require rehabilitation or impede activities of daily living. Elite athletes with great toe fractures are the exception. If rehabilitation is necessary, then the goal is to return the individual to full function with a painless, mobile foot. The duration of treatment is related to possible soft tissue involvement and to the type of fracture. Protocols for rehabilitation must be based upon stability of the fracture and fracture management (operative, nonoperative) (Murphy).

When sesamoid fractures require surgical removal, weight bearing is delayed for up to 3 weeks and return to light jogging may be allowed at 8 weeks. Other cases may be casted from 3 to 8 weeks, then progressed to a stiff-soled or rocker bottom shoe until symptoms resolve. Range of motion exercises should be used after treatment, and are typically initiated at 2 to 3 weeks (Murphy).

Modalities such as cold and compression wrapping may be used when necessary to control pain and edema. Gait training using appropriate assistive devices is indicated to promote independent ambulation. When indicated, the physical therapist progresses the individual's range of motion and proprioceptive and strengthening exercises until a normal gait and full function are evident. Orthotics may be indicated in some cases to protect the foot, relieve discomfort, and promote a functional gait pattern.

If operatively managed, the protocol of rehabilitation will be dictated by the treating physician.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistFracture, Forefoot (Sesamoid, Phalanges)
Physical TherapistUp to 10 visits within 6 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

Because many of these fractures are associated with crushing trauma to the forefoot, extensive soft tissue damage may be the greater problem. Infection, tendon and nerve destruction, and vascular compromise may complicate the injury and treatment. Fracture-dislocation, especially of the great toe, is more challenging to treat. Any underlying medical condition that affects circulation of the foot will complicate treatment. As with all fractures, osteoarthritis and osteomyelitis are possible complications.

Surgical removal of either or both sesamoids may lead to a variety of foot deformities.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Restrictions may include partial or non weight bearing on the affected limb and limited walking, climbing, and squatting. Use of assistive devices such as a cane, crutches, or walker may be necessary. When injuries are severe or involve soft tissue damage to both feet, a wheelchair may be necessary to provide elevation and restricted weight bearing. Accommodations may include frequent rest periods to allow the individual to lie down with the foot elevated. It should be noted that while the injury may appear trivial, the pain and restriction of activity can be quite dramatic. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

Temporary work restrictions may be necessary due to walking boots, casts, or other special footwear requirements. Professional dancers may face pressure from themselves and others to return to practice or performance prematurely. Casting may be used for those at risk for noncompliance, caution must be used as a cast cannot be quickly removed if significant swelling were to occur. Extreme care must be exercised in the case of individuals with diabetes who are at increased risk to develop foot ulcers. All symptoms of forefoot fracture must be resolved before any return to activity is allowed (Goulart). A gradual return to activity while monitoring training volume and proper technique can reduce the risk of recurrence and maximize healing potential (Prisk).

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:

  • Were individual's presenting symptoms consistent with a diagnosis of forefoot fracture?
  • Was diagnosis confirmed with x-rays?
  • If diagnosis was uncertain, were other conditions ruled out?
  • Were there concomitant soft tissue injuries?

Regarding treatment:

  • Was treatment appropriate for the type of fracture?
  • Was surgery required?
  • Was pain managed effectively with NSAIDs?
  • If not, were other pain management interventions tried?
  • Were corticosteroid injections necessary?
  • Is rehabilitation required?

Regarding prognosis:

  • Has adequate time elapsed for recovery?
  • Is individual considered at risk for noncompliance with treatment regimen?
  • Does individual have degenerative arthritis of the feet, osteoporosis, calcium deficiency, tendinitis, bursitis, sesamoiditis, diabetes, peripheral vascular disease, or obesity that might slow recovery?
  • Have appropriate accommodations and job reassignments been made?
  • Were training, practice, or work regimens evaluated for use of proper technique?
  • Did individual experience any complications that could affect recovery?

Source: Medical Disability Advisor



References

Cited

Goulart, Megan, et al. "Foot and Ankle Fractures in Dancers." Clinics in Sports Medicine 27 2 (2008): 295-304. National Center for Biotechnology Information. National Library of Medicine. 2 Mar. 2009 <PMID: 18346544>.

Murphy, G. Andrew. "Chapter 86 - Fractures and Dislocations of the Foot." Campbell's Operative Orthopaedics. Eds. S. Terry Canale and James H. Beaty. 11th ed. Philadelphia: Mosby Elsevier, 2008.

Prisk, Victor R., et al. "Forefoot Injuries in Dancers." Clinics in Sports Medicine 27 2 (2008): 305-320. National Center for Biotechnology Information. National Library of Medicine. 2 Mar. 2009 <PMID: 18346545>.

Source: Medical Disability Advisor






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