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.

Ligamentum Teres Rupture


Differential Diagnosis

Specialists

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

Comorbid Conditions

  • Avascular necrosis
  • Obesity
  • Osteoarthritis
  • Rheumatoid arthritis

Factors Influencing Duration

Length of disability depends on the extent of damage at the hip joint, the presence of comorbid avascular necrosis and osteoarthritis, if surgery was required, and the individual’s job requirements.

Medical Codes

ICD-9-CM:
843.8 - Sprains and Strains of Other Specified Sites of Hip and Thigh

Overview

A ligamentum teres rupture is a severe sprain of the ligament that connects the ball of the hip joint (femoral head) to the hip socket (acetabulum). The ligamentum teres lies deep inside the hip joint and serves as a conduit for arteries to the femoral head. The ligament usually does not come under tension unless the hip joint becomes separated (subluxed), when it is thought to help prevent total hip dislocation. Injuries of the ligamentum teres may result in a complete rupture (Group I tear), a partial tear (Group II tear), or degenerative fraying of the ligament (Group III tear) (Rao).

Rupture of the ligamentum teres most commonly occurs after a traumatic dislocation of the hip joint or from a twisting injury and is typically associated with tears of the cartilaginous ring that surrounds the acetabulum (acetabular labrum) and other joint damage. Partial tears of the ligamentum teres may occur after an episode of hip subluxation. Degenerative fraying of the ligamentum teres occurs when chronic inflammation of the synovial tissues lining the hip joint (synovitis) causes degenerative changes in the hip joint itself (osteoarthritis). When torn fibers of the disrupted ligamentum teres catch within the hip joint, pain occurs.

Incidence and Prevalence: Up to 2.5% of all sports injuries occur in the hip region (Bare). In one study, 15% of individuals undergoing arthroscopic hip surgery were found to have a ligamentum teres rupture (Byrd); of those individuals affected, 56% had sustained a major trauma or a twisting injury (Byrd).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Risk of ligamentum teres rupture is increased with major trauma, such as in a motor vehicle accident (e.g., the lower extremity hitting the dashboard), falling from a height, and during contact or collision sports activities such as ice hockey or football.

Degenerative fraying of the ligamentum teres that can lead to rupture is associated with underlying inflammatory conditions such as osteoarthritis, rheumatoid arthritis, and autoimmune disorders.

Source: Medical Disability Advisor



Diagnosis

History: The individual may report the sudden onset of deep groin or thigh pain, which worsens during weight bearing and with certain leg movements. There may be a history of major trauma or of a twisting injury to the affected leg. Older individuals may report a slow (insidious) onset of groin and thigh pain without associated trauma. The individual may report a clicking sensation of the hip joint with certain movements, and an intermittent feeling that the leg might "give way" when walking.

Physical exam: Moving the affected leg into combined flexion, adduction, and external rotation may stress a partially torn or frayed ligamentum teres and reproduce painful symptoms. Anterior hip impingement testing, in which the affected limb is passively moved into combined flexion, adduction, and internal rotation, may reveal pain and limited range of motion. There may be audible or palpable clicking of the hip joint region when the examiner moves the affected limb. The individual may be observed to walk with a limping (antalgic) gait pattern.

Tests: X-rays may be performed to rule out hip osteoarthritis and underlying malalignment of the hip joint (hip dysplasia); however, tears of the ligamentum teres are not visible on plain x-ray. Computed tomography (CT) scans may help to visualize loose bodies within the joint. Magnetic resonance imaging (MRI) arthrography, in which a contrast dye is injected and then the hip joint is scanned, may be used to view the soft tissue structures (ligament, cartilage) inside. At times, the diagnosis of ligamentum teres rupture is only confirmed after diagnostic hip arthroscopic surgery has been performed.

Source: Medical Disability Advisor



Treatment

If symptoms of ligamentum teres tears are intermittent or mild, conservative treatment is indicated using nonsteroidal anti-inflammatory drugs (NSAIDs), daily activity modification to reduce prolonged weight bearing and aggravating movements of the hip, and cessation of sports activities that may increase hip pain.

Corticosteroid injection into the hip joint (intra-articular injection) may help to reduce painful inflammation associated with ligament tears.

Surgery may be necessary to trim and remove loose ligament fragments, and may be performed arthroscopically (arthroscopic débridement) (Bare). If a severe hip joint fracture or avascular necrosis has occurred at the time of the ligamentum teres rupture, the individual may need a total hip arthroplasty.

Source: Medical Disability Advisor



Prognosis

Following complete ligamentum teres rupture, the hip joint may become unstable and prone to subluxation or dislocation. However, in some cases, the torn ligamentum teres has been observed to heal spontaneously (Schaumkel). Individuals with acute onset of hip pain from ligamentum teres rupture have a better overall prognosis than those with a slow onset of degenerative fraying, typically because degenerative tears are more likely to be associated with hip osteoarthritis (Byrd).

Source: Medical Disability Advisor



Rehabilitation

The focus of rehabilitation for a ligamentum teres rupture is to reduce weight-bearing and twisting forces on the hip and strengthen surrounding hip and trunk musculature to enable a normal gait pattern and independent ambulation. An assistive device (e.g., cane, crutches) may be necessary to temporarily reduce the amount of loading on the affected hip. The individual is instructed in a comprehensive home exercise program that includes joint protection strategies, and is taught strengthening exercises that should be performed within pain free ranges of motion.

Following arthroscopic hip surgery for ligamentum teres rupture, physical therapy first focuses on restoring passive and then active hip range of motion, with progressive strengthening as tolerated. The treating physician guides postoperative rehabilitation with range of motion and weight-bearing restrictions as indicated. Modalities such as ice may be used for pain and swelling. Hip flexibility exercises are performed in accordance with the surgeon's protocol, and strengthening exercises are advanced as tolerated, at first isometrically and then using progressive resistance. Gait training may be necessary to restore normal movement patterns as the individual transitions from using an assistive device to ambulating independently. Low impact exercises and balance and proprioception exercises are introduced as hip strength returns and as weight-bearing status allows.

A home program should be taught to complement supervised rehabilitation, and should be continued after the completion of physical therapy.

Source: Medical Disability Advisor



Complications

Ligamentum teres rupture may result in avascular necrosis of the femoral head. Untreated symptomatic ligamentum teres rupture may result in hip synovitis and osteoarthritis.

Hip arthroscopic surgery has an overall complication rate of 1.3% (Shah). Complications may include injury to nerves and blood vessels, compression injury to the skin of the perineal and foot regions, compartment syndrome, and joint damage.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

The individual may need to use crutches or a walker temporarily when standing or walking to help reduce weight bearing on the affected hip during recovery. Prolonged standing and walking may need to be limited temporarily. The individual may need additional time off to attend rehabilitation sessions during recovery if surgery was necessary. If pain medication is needed upon return to work, company policy should be reviewed to determine if its use is compatible with job safety and function.

Source: Medical Disability Advisor



Regarding diagnosis

Regarding diagnosis:
  • Did individual report a sudden onset of deep groin or thigh pain after a traumatic event? Twisting injury?
  • Was pain worse with weight bearing? Did hip give way when walking?
  • Did individual report a clicking sensation of the hip joint?
  • Have other conditions with symptoms similar to ligamentum teres rupture been ruled out (e.g., avascular necrosis, femoral acetabular impingement, stress fracture, adductor muscle strain, hip dysplasia)?
  • Did moving the affected leg into combined flexion, adduction, and external rotation reproduce painful symptoms?
  • Did anterior hip impingement testing, in which the affected limb is passively moved into combined flexion, adduction, and internal rotation, reveal pain and limited range of motion?
  • Was there audible or palpable clicking of the hip joint region when the examiner moved the affected limb?
  • Was individual observed to walk with antalgic gait pattern?
  • Were x-rays performed? CT scan? MRI arthrography?
  • Was diagnostic hip arthroscopic surgery necessary?

Regarding treatment:

  • Did individual respond to conservative treatment using NSAIDs, daily activity modification, and cessation of sports activities?
  • Was corticosteroid intra-articular injection indicated? Was it helpful?
  • Was surgery necessary to debride hip joint? Was it helpful?
  • Did individual need total hip arthroplasty?
  • Is individual compliant with weight-bearing restrictions and use of an assistive device as directed by the treating physician?
  • Is individual attending physical therapy as prescribed? Is individual performing home exercise program?

Regarding prognosis:

  • Did symptoms resolve with conservative treatment?
  • Did individual require surgery? What type?
  • Was individual compliant with rehabilitation? Home exercise program?
  • Were modifications made to the individual’s work environment during recovery?
  • Does individual have any comorbid conditions that may interfere with a full recovery?
  • Did adequate time elapse for full recovery?

Source: Medical Disability Advisor



References

Cited

Bare, Aaron A., and Carlos A. Guanche. "Intra-articular Lesions." Practical Orthopaedic Sports Medicine and Arthroscopy. Eds. Donald H. Johnson, et al. 1st ed. Lippincott, Williams & Wilkins, 2006. 473-529.

Byrd, J. W., and Kay S. Jones. "Traumatic Rupture of the Ligamentum Teres as a Source of Hip Pain." Arthroscopy 20 4 (2004): 385-391. PubMed. 8 Dec. 2008 <http://www.nsmoc.com/files/pdfs/ligteres.pdf>.

Rao, J., Y. X. Zhou, and R. N. Villar. "Injury to the Ligamentum Teres. Mechanism, Findings, and Results of Treatment (Abstract)." Clinics in Sports Medicine 20 4 (2001): 791-799. PubMed. 8 Dec. 2009 <PMID: 11675887>.

Schaumkel, J. V., and R. N. Villar. "Healing of the Ruptured Ligamentum Teres After Hip Dislocation – An Arthroscopic Finding (Abstract)." Hip International : The Journal of Clinical and Experimental Research on Hip Pathology and Therapy 19 1 (2009): 64-66. PubMed. 8 Dec. 2009 <PMID: 19455505>.

Shah, Agam, and Brian Busconi. "Chapter 21, Hip, Pelvis, and Thigh." DeLee and Drez’s Orthopaedic Sports Medicine. Eds. Jesse C. DeLee, David Drez, and Mark D. Miller. 3rd ed. Saunders Elsevier, 2009. MD Consult. Elsevier, Inc. 8 Dec. 2009 <http://www.mdconsult.com/das/book/body/173275917-4/922057051/2079/43.html#4-u1.0-B978-1-4160-3143-7..00021-X--s0565_3304>.

Source: Medical Disability Advisor






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