Case Manager's Corner

Case Manager’s Corner is designed to provide succinct information concerning some of the most common work related injuries; their mechanism of injury, diagnostic studies, treatments, and expected recovery times. This information is intended only as a guideline and each case may vary with treatment options and recovery time.

Knee:

ACL Tears:
A force to the posterior aspect of the knee usually causes this injury. Physical examination can be very reliable in the diagnosis of this injury but an MRI will provide added information needed prior to surgical reconstruction. Treatment ranges from observation, medication, physical therapy, and bracing to surgical repair. Recovery may take as long as four to six months depending on the job requirements. Those individuals required to perform high impact duties may need additional time and bracing to protect the graft. All patients will be required to wear their ACL brace for approximately six months.

Meniscal Tears:
These usually occur with a twisting injury to the knee but may also occur from degenerative fraying of the articulating cartilage. Meniscal tears do not tend to heal on their own and eventually lead to arthroscopic repair versus debridement. An MRI may not be required in certain situations. The recovery varies depending on the severity of the tear, whether the tear is repaired or debrided, and co-morbid disease. If the tear is repaired the knee is placed in a brace for approximately six weeks. Physical therapy plays a large role in recovery with knee arthroscopy.

Chondromalacia:
Chondromalacia or “softening of the cartilage” may result from chronic irritation or trauma to the articulating cartilage. This afflicts older individuals more so than young, however; trauma may lead to a lesion of cartilage damage in patients of any age. This may be treated conservatively with Anti-inflammatory medications, steroids, Hyaluronate injections, physical therapy, and arthroscopy. This disease process may result in chronic swelling and pain of the knee. Recovery time varies greatly from patient to patient.

Osteochondritis Dissecans:
This term refers to the inflammation and separation of the bone and cartilage. This is usually found on the medial femoral condyle, but may also occur less often in the elbow, ankle, femoral head, and wrist. As the lesion progresses, a sense of locking and instability is felt, along with swelling and pain. No specific trauma may be recalled. Eventually, the cartilage flakes off producing loose bodies that may lock the joint in extension. Treatment options include cartilage transplants and joint replacements. Recovery may last as long as three months or more for total joint replacements and result in permanent work restrictions.

Shoulder:

AC Joint Separation
Traumatic injuries to the shoulder involving direct force or falling on an outstretched arm typically result in these type of injuries. AC separations are classified into Grades I through III. Treatment of Grade I separations are usually non-operative consisting of injections, Physical Therapy, and anti-inflammatories. Grade III are usually treated surgically. Grade II AC separations are typically first treated non-operatively and only result in surgical fixation if not improved. Function is rarely affected and therefore most individuals may continue their work with mild limitations. Full work status is usually achieved in 8-12 weeks.

Rotator Cuff Tears
Most rotator cuff tears are due to age related wear on the muscles and tendons. The supraspinatus tendon is the most often affected. Left untreated, the affected shoulder may go on to “Cuff-Tear-Syndrome”, resulting in the need for further surgery. Symptoms include weakness, loss of motion, and pain in the lateral upper arm. The diagnosis is made largely by physical examination but an MRI is often ordered to evaluate the extent of the tear. Most patients will succumb to surgical repair to improve pain, ROM, and strength. Recovery from surgery is lengthy and involves extensive physical therapy. A pillow (Abductor) sling is worn for approximately six weeks, followed by another six weeks of wearing a regular sling. The patient then begins strengthening at the appropriate time.

Labral Tears
Labral tears are usually caused by trauma to the shoulder resulting in subluxation or dislocation of the joint itself. The tear in the labrum may present with pain, locking, popping, snapping, or joint instability. The most common direction of instability associated with SLAP (Superior Labrum Anterior and Posterior) lesions is in the anterior direction. Diagnosis is made by physical examination and supported by findings consistent with Labral tears by MRI. These require surgical repair by arthroscopy. Recovery is slow and requires extensive therapy lasting up to 3 months. Permanent disability from these injuries is rare.

Impingement Syndrome
The term impingement syndrome, or Rotator Cuff Tendonitis, refers to a mechanical cause of irritation on the Rotator Cuff and Biceps Tendon. This is often caused by repetitive abducted motion of the shoulder, resulting in impingement of the rotator cuff on the lateral Acromion process of the shoulder blade (Scapula). Treatment first consists of Anti-inflammatory medicines, Physical Therapy, Steroid injections, and avoidance of the aggravating motion. If this fails, surgical “decompression” is performed arthroscopically. There is a high surgical success rate for relieving the symptoms mentioned above. Recovery is quite fast and patients return to their normal daily activities within six to eight weeks. Limited duty is recommended during the recovery period to allow adequate healing of the inflamed rotator cuff. Left untreated the rotator cuff may go on to partial or full thickness tears.

Shoulder Dislocations
Dislocation of the shoulder occurs by either blunt force to the upper arm, or from excessive rotational force produced by the patient during sports such as pitching a baseball. This injury is very painful and may require reduction of the joint in the Emergency room. First time dislocations are usually treated with appropriate immobilization and then physical therapy. If the dislocation is recurrent, surgical repair is common to prevent further subluxation/dislocation. Recovery can be lengthy, but light duty may be stated within one to two weeks with strict limitations of no use of the affected extremity. There may be some permanent loss of motion of the joint.