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.

Repair, Ruptured Achilles Tendon


Related Terms

  • Achilles Tendon Repair

Specialists

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

Comorbid Conditions

  • Diabetes mellitus

Factors Influencing Duration

The severity of the tendon tear, the health of the tendon, the treatment required, any complications, and the amount of weight bearing required for job activities may affect disability. Duration of disability depends on job requirements and whether job duties can be performed in a seated position. Heavy work usually is not compatible with Achilles tendon rupture.

Medical Codes

ICD-9-CM:
83 - Operations on Muscle, Tendon, Fascia, and Bursa, Except Hand
83.1 - Division of Muscle, Tendon, and Fascia
83.11 - Achillotenotomy
83.62 - Delayed Suture of Tendon
83.64 - Suture of Tendon, Other; Achillorrhaphy; Aponeurorrhaphy
83.8 - Plastic Operations on Muscle, Tendon, and Fascia, Other
83.85 - Other Change in Muscle or Tendon Length; Hamstring Lengthening; Heel Cord Shortening; Plastic Achillotenotomy; Tendon Plication

Overview

Repair of a ruptured Achilles (calcaneal) tendon is a procedure to repair a tear in the Achilles tendon, the tough cord of fibrous connective tissue that attaches the calf muscles to the heel bone (calcaneus). The tear, which may be partial or complete, results from over-stretching the tendon and can occur anywhere along its length, but most commonly occurs about 2 to 6 cm above the calcaneus (Nannini, Jacobs). The left Achilles tendon is more vulnerable to rupture than the right, perhaps due to increased left foot push-off in right-handed individuals (Jacobs).

Treatment may involve either surgical correction (open or percutaneous surgery) or rest with supportive devices such as a functional brace or rigid cast. Generally, surgery is encouraged for because it provides more rapid return to activity and better long-term outcome with regard to re-rupture rates. Physical therapy follows both approaches after there has been sufficient healing and is critical to a successful outcome.

Several surgical techniques are available, but the surgeon will always strive to have the torn ends mesh, conforming to their original configuration and restoring normal tendon length. This may be done as an open procedure or by percutaneous repair, which is achieved through small stab incisions. In some cases in which the condition of the tendon is compromised and requires added support, local tissue such as fascia may be grafted on the repair site to reinforce the repair. Anesthesia for both the open and percutaneous surgeries can be either general or regional. Moderate discomfort will follow surgery, but this can be addressed with a pain management plan and/or medications.

Nonsurgical treatment involves the individual wearing a cast or other immobilizing device, giving the tendon time to heal on its own. This option usually is reserved for individuals with partial tears, the elderly, or individuals with poor wound healing prospects such as those with diabetes.

Although the Achilles tendon is the largest and strongest tendon in the body, the tremendous stresses brought to bear on it through activities requiring quick pivoting movements, jumping, or sprinting, increase the risk of rupture. Also, from aging or inactivity, the tendon weakens and becomes vulnerable to injury; this results in Achilles tendon ruptures occurring more commonly in 30 to 50 year olds than in younger athletes. Certain diseases such as rheumatoid arthritis and diabetes also increase the risk of rupture, as does use of certain medications, including corticosteroids and certain antibiotics such as fluoroquinolones.

Source: Medical Disability Advisor



Reason for Procedure

Achilles tendon repair is used to bring the ruptured tendon back to its normal configuration and promote healing of the tissue with the best possible outcome. Surgical repair is especially encouraged for those engaging in high-impact sports, heavy or very heavy work, and for complete rupture, large partial rupture, or re-rupture of the tendon.

Source: Medical Disability Advisor



How Procedure is Performed

The surgeon makes a lengthwise incision through the skin over the injured tendon until the membranous covering (tendon sheath) is exposed. The sheath is then opened, exposing the damaged tendon. The surgeon cuts away some of the damaged fibers and prepares to join the tendon ends, always mindful of preserving the tendon's length. Sutures are woven through the tendon in a manner that will best support the tendon during healing, and then the tendon ends are pulled together. Finally, the incision is closed, and the patient is fitted with a splint.

The above is a broad outline of the open procedure. Refinements, necessity, and the surgeon's personal preferences may vary the procedure slightly. Some surgeons make the incision somewhat medial to the tendon in the hope of avoiding a pressure slough or adhesions and to better visualize the local (sural) nerve. Other surgeons use a lateral approach. Various suturing techniques are used, but they all strive for the best possible apposition of the tendon ends and the avoidance of over-tightening the repair, which may shorten the tendon length. Additionally, the surgeon may elect to augment the tendon site with fascia, a tough membranous muscle covering, taken from a nearby site, or with healthy tendon tissue transferred onto the repair site.

Percutaneous repair is considered when the patient is unlikely to engage in sports that create excessive demands on the tendon. It has the advantage of lower wound complications than the open technique and has a comparable re-rupture rate (3%) (Cretnik). Here too, there are surgical variations. The following describes one technique: A 3 cm (1.2 in) incision is made across and directly over the injured site. The surgeon then makes two similar, parallel incisions, each about 4 cm (1.6 in) away from the first, one above and one below the initial incision. Suture material is then threaded in and out of the incisions so that the torn ends of the tendon can be joined and locked in place.

Following surgical repair, the individual is fitted with a supportive device (walking boot, splint, cast, or brace) to be worn for about 6 weeks. At first the foot is pointed downward to avoid tension on the repair site, and then incrementally the foot is returned to a neutral position, thereby bringing the tendon back to its normal length. Gradual weight bearing may begin after 4 to 6 weeks. Treatment, splinting, and physical therapy options must consider the potential for muscular atrophy. The ability of the individual to engage in early range of motion exercises marks a clear advantage for surgical repair.

In nonsurgical treatment, the individual will be fitted with an immobilizing device such as a cast, which at first points the foot slightly downward, hoping to keep the damaged ends better opposed. Gradually, after about 4 to 6 weeks, the foot is elevated to a neutral position. A walking cast may then be used. Even after this cast is removed, the patient will need to wear a shoe fitted with a heel lift for 2 to 4 months.

Source: Medical Disability Advisor



Prognosis

The prognosis following Achilles tendon rupture is good with either surgical or nonsurgical treatment. However, with surgery, athletes can return to activity sooner, and the recurrence rate is less than 5%, whereas individuals following the nonsurgical approach experience a 14% to 30% re-rupture rate (Strauss). With open surgery, 96% of individuals report good-to-excellent outcomes at 45-month postoperative follow-up (Strauss). Surgical reconstruction is the favored approach in most cases to optimize function, full ankle range of motion, and endurance (Kocher); however, surgical approaches are associated with complications in 5.5% of individuals (Lansdaal). After percutaneous Achilles tendon repair, 98% of individuals are able to return to their previous activity levels, including sports (Cretnik). Regardless of whether Achilles tendon repair surgery is performed early or delayed (>4 weeks after injury), most individuals are able to return to normal activities within 100 days (Sorrenti). The prognosis becomes less optimistic with successive rupture of the same tendon (Metzl).

Source: Medical Disability Advisor



Rehabilitation

The goals of rehabilitation following an Achilles tendon rupture and repair are to control pain and to return the individual to full function with a painless, mobile ankle. The duration of treatment is related to functional mobility, healing response, the length of post-operative immobilization, the surgical procedure performed, and any complications.

Rehabilitation should emphasize restoring full range of motion, strength, proprioception, endurance, and a normal gait pattern. While the resumption of pre-injury status is the goal, the type of rupture (partial, complete) will affect the speed of rehabilitation. Protocols for rehabilitation must consider the type of rupture management (operative, nonoperative) and must be guided by the treating physician.

To prevent complications of inactivity, individuals should be encouraged to continue functional activities that do not compromise the status of the healing tendon. If the Achilles tendon is partially torn or the individual is treated nonsurgically, a short leg cast or functional ankle brace may be applied with the ankle in progressively decreasing plantar flexion until healing is complete. Physical therapy may then be initiated for range of motion activities, gait training, and careful strengthening exercises. The individual is progressed to normal footwear with a 2 cm heel lift for an additional 2 to 4 months to avoid strain on the healing tendon as functional mobility returns (Wheeless).

Following surgical repair (open approach or percutaneous repair), the ankle may be immobilized with a posterior splint for the initial 10 days to reduce tension on the tendon and incision, followed by a walking boot to allow removal for therapy sessions. In therapy, individuals begin with ankle joint mobilization and non-weight-bearing passive range of motion activities to promote ankle flexibility, which may improve recovery time without increasing complications (Mortensen). Individuals may perform range of motion exercises of the adjacent joints unless contraindicated. Non-weight-bearing range of motion exercises are followed by progressive resistance exercises to help reduce muscular atrophy. Individuals are allowed to gradually increase weight-bearing exercise and walking with the boot on and then off according to physician protocol (Wheeless).

It is important to maintain at least a 1-inch (2.5-cm) heel lift (approximately 10° of plantar flexion) during early ambulation following Achilles tendon repair to minimize over-activity of the calf muscle and to allow tendon healing (Akizuki). Therapists should instruct the individual to use assistive devices as needed to promote independent ambulation and may progress the individual from crutches to cane according to weight-bearing status and ability. In general, after the initial 2 weeks post surgery, early weight bearing results in improved functional abilities, activity levels, and return to work as compared to delayed weight bearing beginning at 6 weeks post surgery (Suchak). With a heel support, the individual typically can return to full weight bearing at 8 weeks (Mafulli). Exercise intensity and difficulty may be progressed until full function is evident. Before discharge from therapy, the individual should be instructed in a home program to continue independently. Throughout rehabilitation, the therapist monitors for potential complications such as severe swelling (edema), complex regional pain syndrome, tendon rupture, joint stiffness, or infection.

Source: Medical Disability Advisor



Complications

Complications include infection, development of adhesions, decreased ankle range of motion, muscle atrophy and weakness, nerve injury, blood clots (deep venous thrombosis; pulmonary embolism), skin sloughs, heel ulcers, hematoma formation, and re-rupture of the tendon. Nerve damage may produce a neuroma and/or result in a local sensory deficit.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

The surgical site must be protected until the physician considers it sufficiently healed. Work restrictions and accommodations may include the avoidance of weight-bearing activity and the use of crutches or a walker until recovery is complete. The ability to climb stairs or ladders, stand for long periods, walk long distances, and drive a motor vehicle may be limited. Frequent rest periods may be necessary. Time off for physical therapy sessions must be accommodated. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

Median time for return to work following minimally invasive Achilles tendon repair is 28 days (range1 to 368 days), and median time for returning to sport activities is 167 days (range 31 to 489 days) (Lansdaal).

Source: Medical Disability Advisor



References

Cited

Akizuki, K. H., et al. "The Relative Stress on the Achilles Tendon During Ambulation in an Ankle Immobiliser: Implications for Rehabilitation after Achilles Tendon Repair." British Journal of Sports Medicine 35 5 (2001): 329-333. National Center for Biotechnology Information. National Library of Medicine. 9 Jul. 2009 <PMID: 11579067>.

Cretnik, A., M. Kosanovic, and V. Smrkolj. "Percutaneous Suturing of the Ruptured Achilles Tendon Under Local Anesthesia." Journal of Foot and Ankle Surgery 43 2 (2004): 72-81. PubMed. <PMID: 15057852>.

Jacobs, Brian, David Y. Lin, and Evan Schwartz. "Achilles Tendon Rupture: Treatment & Medication." eMedicine. Eds. David T. Bernhardt, et al. 24 Jun. 2009. Medscape. 9 Jul. 2009 <http://emedicine.medscape.com/article/85024-overview>.

Kocher, M. S. , et al. "Operative Versus Nonoperative Management of Acute Achilles Tendon Rupture: Expected-Value Decision Analysis." American Journal of Sports Medicine 30 6 (2002): 783-790. PubMed. <PMID: 12435641>.

Lansdaal, J. R., et al. "The Results of 163 Achilles Tendon Ruptures Treated by a Minimally Invasive Surgical Technique and Functional Aftertreatment." Injury 38 7 (2007): 839-844. PubMed. <PMID: 17316642>.

Maffulli, N., et al. "Favorable Outcome of Percutaneous Repair of Achilles Tendon Ruptures in the Elderly." Clinical Orthopaedics and Related Research 1039-1046. PubMed. 19 Jun. 2009. 9 Jul. 2009 <PMID: 19543777>.

Metzl, J. A., C. S. Ahmad, and W. N. Levine. "The Ruptured Achilles Tendon: Operative and Non-operative Treatment Options." Current Review of Musculoskeletal Medicine 1 2 (2008): 161-164.

Mortensen, Niels Henrik Maagaard, O. Skov, and P. E. Jensen. "Early Motion of the Ankle After Operative Treatment of a Rupture of the Achilles Tendon. A Prospective, Randomized Clinical and Radiographic Study." Journal of Bone and Joint Surgery 81 (1999): 983-990. Journal of Bone and Joint Surgery, Inc. 9 Jul. 2009 <http://www.ejbjs.org/cgi/content/abstract/81/7/983>.

Nannini, Christopher. "Achilles Tendon Rupture." eMedicine Health. Eds. Scott H. Plantz, et al. 13 Jan. 2006. WebMD, LLC. 15 Aug. 2009 <http://www.emedicinehealth.com/fulltext/4504.htm>.

Sorrenti, S. J. "Achilles Tendon Rupture: Effect of Early Mobilization in Rehabilitation After Surgical Repair." Foot & Ankle International 27 6 (2006): 407-410. PubMed. <PMID: 16764795>.

Strauss, E. J., et al. "Operative Treatment of Acute Achilles Tendon Ruptures: An Institutional Review of clinical Outcomes." Injury 38 7 (2007): 832-838. PubMed. <PMID: 16945370>.

Suchak, A. A., et al. "The Influence of Early Weight-bearing Compared with Non-weight-bearing After Surgical Repair of the Achilles Tendon." Journal of Bone and Joint Surgery 90 9 (2008): 1876-1883. PubMed. <PMID: 18762647>.

Wheeless, Clifford. "Achilles Tendon Rupture: Non Operative Treatment." Wheeless' Textbook of Orthopedics. Eds. Nina Lightdale, Justin Field, and Christopher Danney. Durham: Medmedia.com, 1996. Wheeless' Textbook of Orthopaedics. Duke Orthopaedics. 9 Jul. 2009 <http://www.wheelessonline.com/05/243a.htm>.

Source: Medical Disability Advisor






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