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.

Sprains and Strains, Ankle


Specialists

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

Comorbid Conditions

Factors Influencing Duration

Severity of the sprain, amount of swelling, complications associated with the injury, and the individual’s particular job requirements all influence the length of the disability.

Medical Codes

ICD-9-CM:
727.67 - Rupture of Tendon, Nontraumatic, Achilles Tendon
845 - Sprains and Strains of Ankle and Foot
845.0 - Sprains and Strains, Ankle
845.00 - Sprains and Strains, Ankle, Unspecified Site
845.01 - Sprains and Strains, Ankle, Deltoid (Ligament) Ankle; Internal Collateral (Ligament) Ankle
845.02 - Sprains and Strains, Ankle, Calcaneofibular Ligament
845.03 - Sprains and Strains, Ankle, Tibiofibular Ligament, Distal
845.09 - Sprains and Strains, Ankle, Other; Achilles Tendon

Overview

An ankle sprain is an injury to the ligaments around the ankle. An ankle strain is an injury to the tendons or muscles around the ankle. Ankle sprains and strains involve the stretching or tearing of tissue of the ligaments or the muscle-tendon unit, respectively.

Sprains are classified according to the amount of tearing of the ligament. A first-degree sprain is one in which the ligament fibers are over-stretched but intact. A second-degree sprain is one in which some fibers are actually torn. A third-degree sprain is one in which the ligament is completely torn and nonfunctioning.

Strains can be categorized by the same manner as sprains, with first-degree indicating over-stretching, second-degree indicating partial tear, and third-degree indicating complete tear (rupture). Strains of the ankle are generally mild (first-degree). They are similar to sprains in the mechanism of injury, treatment, and prognosis.

An ankle sprain is typically caused by sudden, strong contraction, torsion, direct impact, or by a sudden, forceful straightening. Ankle sprains usually occur as a result of forcibly twisting the ankle or by landing from a jump on a foot that is turned in (inversion) or out (eversion). Basketball has the highest rate of ankle sprains of any sport. Sprains can also occur in football, soccer, volleyball, skiing, and martial arts.

Strains are either partial or complete tears of muscle-tendon units, usually the result of strong muscular contraction sustained in forceful stretching. They typically occur from the same activities and stresses as sprains, but are uncommon about the ankle joint. The tendons that traverse the ankle joint (peroneal tendons laterally; tibialis posterior and toe flexor tendons medially; tibialis anterior and toe extensor tendons anteriorly; the Achilles tendon posteriorly) are usually strained or ruptured at their point of insertion in the foot, rather than at the ankle level. The only exception to this is the Achilles tendon behind the ankle. This tendon can be strained in the leg, ankle, or foot.

The most common ankle injury is the lateral inversion ankle sprain, which accounts for 85% of all ankle sprains (Young). It occurs as the foot and ankle roll over sideways, causing damage to the ligament that connects the fibula to the talus and calcaneus. Another classification system for sprains (Leach classification) is based on which of the three ligaments in the area are torn (ruptured). A first-degree sprain is a rupture of the anterior talofibular ligament, a second-degree sprain is a rupture of both the anterior talofibular and calcaneofibular ligaments, and a third-degree sprain is rupture of both of these ligaments plus the posterior talofibular ligament. When the foot is turned out (eversion) during the injury, damage is to the inside (medial) of the ankle. The four ligaments in this area are called the deltoid ligaments. They are much stronger than the lateral ankle ligaments and rarely rupture. In fact, the bone insertion of these ligaments (medial malleolus) will usually fracture (avulsion fracture) before the ligament ruptures. A much less common sprain occurs to the ligament between the tibia and fibula (syndesmosis). This injury is called diastasis of the tibiofibular syndesmosis, or a "high" ankle sprain, and causes significant disability. This injury occurs when force is transmitted from the foot up the center of the ankle joint, such as landing on the foot from a height. Part of the function of ankle ligaments involves communicating with the nervous system via a stimulus feedback mechanism (proprioception) to help the individual maintain balance. When the ligaments are sprained, this important proprioceptive function may be distorted or lost, resulting in inversion injuries. It has been suggested that repeated “going over the ankle” (inversion injuries) may be due more to proprioceptor damage than to unstable ligaments (Cox).

Incidence and Prevalence: Ankle sprains are one of the most common injuries presented for treatment. Daily incidence of ankle sprains in the US is estimated at 1 person in every 10,000. Most sprains result from athletic injuries, accounting for 15% of all athletic injuries (Foster).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals who participate in athletic activities are more likely to experience ankle sprains and stains.

Source: Medical Disability Advisor



Diagnosis

History: Individuals with a first-degree sprain or strain may not experience any symptoms until a day or so after injury, although these injuries do commonly cause mild immediate pain. Those with a second- or third-degree strain or sprain will describe an injury with a twisting of the ankle and often an audible "pop." Pain and swelling immediately after the injury are more common after a second- or third-degree injury.

Individuals are most often unable to tolerate any weight bearing on the ankle. Pain over the lower leg, just above the ankle, is more common with a syndesmosis injury. A history of previous injuries should be obtained, even if no treatment was sought, as a previous injury could make the ankle unstable and more susceptible to repeat injury.

Physical exam: Local or diffuse swelling and bruising (ecchymosis) is noted. Pain may be localized to the ligaments involved or, more generally, over the lateral, medial, or anterior portion of the ankle. Manual stress of the ligaments may reveal looseness (laxity) of the ankle joint and increased pain. Stress testing of the other ankle is done for comparison (a ruptured ankle ligament will cause the injured ankle to be looser, or more lax, than the uninjured ankle).

Tests: Routine x-rays are done whenever swelling and tenderness are present to rule out damage to the bones, especially avulsion fractures. Special x-rays (stress views) will allow evaluation of ligament stability by taking the x-ray while the anesthetized ankle is manually stressed. Stress views of the contralateral ankle are taken for comparison. The spaces between the talus and fibula (or tibia) are measured and compared between the two ankles, with an increased space indicating instability. In addition, the angle of "tilt" between the top surface of the talus and the bottom surfaces of the tibia and fibula (talar tilt) is measured in both ankles and compared, with an increase in talar tilt indicative of instability. A CT scan may be ordered if avulsion fractures or talar dome fractures are suspected. Arthrography to detect ligament and joint capsule tears is useful only in the first 5 to 7 days after injury, after which blood clotting will seal these defects. MRIs are useful for planning surgical reconstruction of ligaments.

Source: Medical Disability Advisor



Treatment

The emergency treatment of all ankle sprains and strains is rest, ice, compression, and elevation (RICE). Early mobilization of the ankle is essential to avoid stiffness. Protective immobilization with a pneumatic stirrup or lace-up ankle brace is usually sufficient treatment for first-degree sprains and first- and second-degree strains. In cases where weight bearing and foot motion are extremely painful, crutches may be used for a brief period. Weight bearing as tolerated is encouraged, however. Casting is generally avoided because prolonged immobilization of the ankle can lead to muscle atrophy and reduced range of motion (Struijs).

Conservative treatment with immobilization is sufficient for all deltoid sprains, unless an avulsion fracture of the medial malleolus is present. Diastasis of the syndesmosis is surgically repaired by suturing of the ligament (modified Bunnell technique) combined with insertion of a transfixion screw through the tibia and fibula to reposition them together (open reduction with internal fixation). Third-degree strains may be treated surgically by sewing (suturing) torn tendon ends together (modified Bunnell technique).

Most lateral ankle sprains are treated with application of an ankle support (elastic wrap, lace-up brace, semi-rigid pneumatic brace), early mobilization, and rehabilitation (Wapner; Krabak). Some third-degree and severe second-degree lateral ankle sprains in highly functioning athletes are treated with surgical repair of the torn ligaments (Broström procedure); however, surgery is generally not necessary in the majority of cases (Krabak). In severe injuries in which chronic instability develops, special reconstructive procedures (lateral ankle reconstruction) may be used. Most of these use tendon or fascia grafts to reconstruct the missing or scarified ligament. These procedures include the Chrisman-Snook procedure, Lee-Evans procedure, and the Watson-Jones procedure.

All surgical procedures usually require postoperative casting and avoidance of any weight bearing for 6 weeks, followed by intensive physical therapy to reduce pain and swelling and to regain strength and range of motion. The proprioceptive function of the ankle ligaments must be restored through rehabilitation in order to avoid repeat ankle inversion injuries and to help the individual maintain normal balance. Anti-inflammatory medications are often prescribed to control pain and swelling.

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

Complete recovery from first-degree sprains and first- and second-degree strains can be expected, even without appropriate treatment. With second- and third-degree sprains, even with appropriate treatment, some individuals will have some subsequent weakness and instability of the ankle (particularly on the lateral side). These individuals may be prone to recurrent injury, and may require an ankle brace for recreational activities and possibly even for normal walking.

Prognosis for conservative versus surgical treatment of ankle sprains remains an area of inquiry. Treatment decisions are currently made on an individual basis while carefully weighing the risks and benefits of each treatment option (O’Loughlin; Kerkhoffs, "Different Functional Treatment"). Some evidence suggests that individuals with second- and third-degree sprains treated surgically with primary repair (Broström procedure) will generally have a better functional ankle than those treated conservatively with casts or braces; however, other studies report that nonsurgical treatment with early mobilization and use of an ankle support brace results in a shorter recovery period and excellent outcomes (Wapner; Krabak). Some individuals with chronic injuries treated with lateral ankle stabilization procedures (Chrisman-Snook procedure or Watson-Jones procedure) emerged with a very stable ankle, but experienced some residual stiffness in the ankle.

Source: Medical Disability Advisor



Rehabilitation

Individuals with sprains and strains of the ankle will benefit from rehabilitation. The rehabilitation will vary depending of the degree of soft tissue damage. Although treatment is similar for all groups, the rate of progression will vary based on the degree of ligament disruption. Following a functional treatment program will promote the quickest recovery, and facilitate the rapid return to work and pre-injury status. Therapy is initiated with PRICE (protection, rest, ice, compression, elevation) (Braddom; Lynch) for the first 48 hours after injury or until swelling has stabilized. The purpose of PRICE is to control the pain and swelling associated with the acute phase of injury. During recovery, ice is also recommended after exercise to control edema and pain. Heat may be applied prior to exercise, once edema is curtailed, to increase circulation to the superficial soft tissue around the ankle. No evidence exists to support the use of ultrasound for ankle sprains (Struijs; Van der Windt).

For these types of injuries, a short period of immobilization and protection with a lace-up semi-rigid support is advised (Kerkhoffs, "Different Functional Treatment"). All supportive devices should be discontinued for routine daily activities when the individual exhibits full pain-free range of motion and ambulation. The treating physician should advise regarding the use of a supportive device during sports or heavy work, which may reduce future injuries (Handall).

A therapeutic exercise program should be started early (Wapner). The comprehensive rehabilitative exercise program should begin with active range of motion, weight-bearing as tolerated, and isometric and isotonic exercises. Functional exercise within the painful limit should be initiated as early as possible (Arnold). Therapists instruct individuals in a home exercise program and progression to use of rubber band resistance once pain-free weight bearing is achieved. Stretching exercises for the Achilles tendon are important to prevent contracture (Krabak). Exercises should be progressed to include proprioceptive training, and the simulation of sports or functional activities (Krabak). A combination of exercises allows for the earliest return to activities of daily living. Osteopathic manual therapy may also be used (Bleakley).

In the past it was believed that immobilization might benefit individuals with third-degree sprains. Those who cannot bear weight 3 days after the injury may be casted for 10 days or receive pneumatic semi-rigid bracing. Either treatment combined with functional therapy has good results (Lamb). Surgery is rarely needed for 3rd degree sprains and strains except in cases with concurrent large avulsion fractures, ankle dislocation, or open injuries (Kerkhoffs, "Different Functional Treatment"; Wapner; Krabak).

Up to 30% of individuals with lateral ankle injuries present with residual pain and/or instability (Lynch). Thorough reassessment is indicated to confirm the original diagnosis. Although full ligament healing usually occurs within 12 weeks, remodeling of the newly healed ligament will continue as a result of the forces imposed during routine weight bearing activities. Often a carefully designed therapeutic exercise program focused on proprioception, muscle strength, muscle reaction time, and postural control can promote full recovery. Some research suggests that secondary surgical ligament repair has results similar to those of primary repair, and therefore conservative management is always indicated (Krabak). Conflicting evidence exists describing the benefits of surgery over functional restoration (Kerkhoffs, “Surgical Versus”; Pijnenburg). Balance and coordination training increases proprioception and may decrease recurrences (Bleakley; McKeon; Wester).

Semi-rigid orthoses or pneumatic braces may be useful for those with continuing pain or instability when engaging in high-risk physical activities. (Handall).

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistSprains and Strains, Ankle
Physical TherapistUp to 16 visits within 8 weeks
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

The most common complication after treatment is recurrent instability. Loose bodies may develop from articular cartilage damage at the time of the injury and, if they enlarge, may require surgical removal. Damage to the interosseous talocalcaneal ligament may occur with an ankle sprain and result in chronic subtalar joint pain (sinus tarsi syndrome). Damage to the top of the talus (talar dome) can result in a loosening of the bone and cartilage there (osteochondritis dissecans).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Restrictions would include limited weight bearing depending on the severity of the injury. Walking, climbing, and squatting should be limited early in the treatment of ankle sprains.

Use of canes, crutches, or walkers may be necessary. Wearing a boot or brace is common. Work release time for physical therapy will be necessary. The use of the foot in driving (for gas pedal or clutch, depending on which foot is involved) is prohibited until the individual has returned to full weight bearing in regular shoes. In some cases, footwear appropriate to the requirements of the job, such as high top shoes, may help stabilize the ankle and prevent recurrence. Avoiding ill-fitting or worn out shoes is also important. Athletes recovering from ankle sprain should be encouraged to continue a program of stretching and balance (proprioception) training on a regular basis.

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:

  • Was diagnosis of ankle sprain/strain confirmed?
  • Does pain persist even after a course of treatment?
  • Were follow-up x-rays done to rule out fractures missed earlier?
  • Does individual have excessive residual swelling?
  • Was MRI performed to evaluate soft tissues?
  • Did individual experience any complications?
  • Has the individual experienced recurrent instability or chronic subtalar joint pain?
  • Does individual have an underlying condition that may affect recovery?

Regarding treatment:

  • Has individual been compliant with treatments, including rest, ice, compression and elevation (RICE)?
  • If recommended, did individual make use of crutches and protective immobilization to reduce or eliminate weight bearing?
  • Are elevation, hydrotherapy, and external compression warranted at this time?
  • Did individual receive physical therapy?
  • Would individual benefit from physical therapy?
  • Was avulsion fracture present? Did it require open reduction with internal fixation?
  • Was surgical repair successful?
  • Were complications a result of the repair procedure?
  • Was reconstruction (Chrisman-Snook, Lee-Evans, or Watson-Jones procedure) required?
  • Did individual receive adequate balance training?

Regarding prognosis:

  • To what degree does instability affect function?
  • Are appropriate precautions, such as an ankle brace, used to enhance function and prevent re-injury?
  • Would individual benefit from a lateral ankle stabilization procedure?
  • Does residual ankle stiffness affect individual's functional ability or occupational requirements?
  • Should consideration be given to more intensive therapy such as aggressive elevation, hydrotherapy treatments, and external compression?
  • Has individual been involved in a comprehensive rehabilitation program?

Source: Medical Disability Advisor



References

Cited

Arnold, B. L., and C. L. Docherty. "Bracing and Rehabilitation--What's New." Clinics in Sports Medicine 23 1 (2004): 83-95. National Center for Biotechnology Information. National Library of Medicine. 10 Dec. 2008 <PMID: 15062585>.

Bleakley, C., S. McDonough, and D. MasAuley. "Some conservative strategies are effective when added to controlled mobilization with external support after acute ankle sprain: a systematic review." Australian Journal of Physiotherapy 54 (2008): 7-20.

Braddom, Randolph L. Physical Medicine and Rehabilitation. 3rd ed. Philadelphia: W.B. Saunders, 2006.

Cox, R., and I. M. Nugent. "Orthopaedics and Trauma of the Limbs." Fitness for Work: The Medical Aspects. Eds. K. T. Palmer, et al. 4th ed. London: Oxford University Press, 2007.

Foster, Ray. "Acute Ankle Sprains." eMedicine. Eds. James K. DeOrio, et al. 4 Feb. 2008. Medscape. 4 Feb. 2009 <http://emedicine.medscape.com/article/1234170-overview>.

Handall, H H G, et al. "Interventions for Preventing Ankle Ligament Injuries." Cochrane Database of Systematic Reviews 3 (2001): NA.

Kerkhoffs, G. M., et al. "Different Functional Treatment Strategies for Acute Lateral Ankle Ligament Injuries in Adults." Cochrane Database of Systematic Reviews 3 (2002): CD002938. National Center for Biotechnology Information. National Library of Medicine. 10 Dec. 2008 <PMID: 12137665>.

Kerkhoffs, G. M., et al. "Immobilisation for Acute Ankle Sprain. A Systematic Review." Archives of Orthopaedic and Trauma Surgery 121 8 (2001): 462-471. National Center for Biotechnology Information. National Library of Medicine. 10 Dec. 2008 <PMID: 11550833>.

Kerkhoffs, G. M., et al. "Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults." Cochrane Database of Systematic Reviews. 2 ed. John. Wiley & Sons, 2007.

Krabak, Brian J., and Jennifer Baima. "Chapter 75 - Ankle Sprain." Essentials of Physical Medicine and Rehabilitation. Eds. Walter R. Frontera, Julie K. Silver, and Thomas Rizzo. 2nd ed. Philadelphia: Saunders, Elsevier, 2008.

Lamb, S., et al. "Mechanical supports for acute, severe ankle sparin: a pragmatic, multicentre, randomized controlled trial." Lancet 373 (2009): 575-581.

Lynch, S. A., and P. A. Renstrom. "Treatment of Acute Lateral Ankle Ligament Rupture in the Athlete. Conservative Versus Surgical Treatment." Sports Medicine 27 1 (1999): 61-71. National Center for Biotechnology Information. National Library of Medicine. 10 Dec. 2008 <PMID: 10028133>.

McKeon, P., and J. Hertel. "Systematic review of postural control and lateral ankle instability, part II: Is balance training clinically effective?" Journal of Athletic Training 43 3 (2008): 305-315.

O'Loughlin, Padhraig, et al. "Ankle Sprains and Instability in Dancers." Clinics in Sports Medicine 27 2 (2008): 247-263.

Pijnenburg, A. C., et al. "Operative and Functional Treatment of Rupture of the Lateral Ligament of the Ankle. A Randomised, Prospective Trial." Journal of Bone and Joint Surgery. British Volume 85 4 (2003): 525-530.

Simons, Stephen, and Robert Kennedy. "Chapter 34 - Foot Injuries." Clinical Sports Medicine: Medical Management and Rehabilitation. Eds. Walter R. Frontera, et al. 1st ed. W.B. Saunders, 2006.

Struijs, Peter, and Gino Kerkhoffs. "Ankle Sprain." BMJ Clinical Evidence Handbook. Ed. Charles Young. BMJ Publishing Group, 2009. 354-355.

Van der Windt, DAWM, et al. "Therapeutic Ultrasound for Acute Ankle Sprains." Cochrane Database of Systematic Reviews. John. Wiley & Sons, 2002.

Wapner, K., et al. "Retrocalcaneal bursitis (Hagland's disease, enlargement of the superior tuberosity of the Os calcis." DeLee and Drez's Orthopaedic Sports Medicine. Eds. Jesse C. DeLee and David Drez. 2 ed. Saunders Elsevier, 2003.

Wester, J., et al. "Wobble board training after partial spains of the lateral ligaments of the ankle: A prospective randomized study." Journal of Orthopadedic Sports Physical Therapy 23 5 (1996): 332-336.

Young, Craig C. "Ankle Sprain." eMedicine. Eds. David T. Bernhardt, et al. 7 Jan. 2008. Medscape. 4 Feb. 2009 <http://emedicine.medscape.com/article/85393-overview>.

Source: Medical Disability Advisor






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