19 Del. Admin. Code § 1342-G-3.0

Current through Register Vol. 27, No. 12, June 1, 2024

Section 1342-G-3.0 - Initial Diagnostic Procedures

The guidelines recommend the following diagnostic procedures be considered, at least initially. It is the responsibility of the workers' compensation carrier to ensure that an accurate diagnosis and treatment plan can be established. Standard procedures that should be utilized when initially diagnosing a work-related lower extremity complaint are listed below.

3.1HISTORY-TAKING AND PHYSICAL EXAMINATION (Hx & PE) are generally accepted, well-established and widely used procedures that establish the foundation/basis for and dictates subsequent stages of diagnostic and therapeutic procedures. When findings of clinical evaluations and those of other diagnostic procedures are not complementing each other, the objective clinical findings should have preference. The medical records can reasonably document the following:

3.1.1History of Present Injury:

3.1.1.1 Mechanism of injury. This includes details of symptom onset and progression. It should include such details as: the activity at the time of the injury, patient description of the incident, and immediate and delayed symptoms. The history should elicit as much detail about these mechanisms as possible.

3.1.1.2 History of locking, clicking, popping, giving way, acute or chronic swelling, crepitation, pain while ascending or descending stairs (e.g. handrail used, 'foot by foot' instead of 'foot over foot') inability to weight bear due to pain, intolerance for standing or difficulty walking distances on varied surfaces, difficulty crouching or stooping, and wear patterns on footwear. Patients may also report instability or mechanical symptoms.

3.1.1.3 Any history of pain in back as well as joints distal and proximal to the site of injury. The use of a patient completed pain drawing, Visual Analog Scale (VAS), is highly recommended, especially during the first two weeks following injury to assure that all work related symptoms are addressed.

3.1.1.4 Ability to perform job duties and activities of daily living.

3.1.1.5 Exacerbating and alleviating factors of the reported symptoms. The physician should explore and report on non-work related as well as, work related activities.

3.1.1.6 Prior occupational and non-occupational injuries to the same area including specific prior treatment and any prior bracing devices.

3.1.1.7 Discussion of any symptoms present in the uninjured extremity.

3.1.2Past History:

3.1.2.1 Past medical history includes neoplasm, gout, arthritis, previous musculoskeletal injuries,AND DIABETES;

3.1.2.2 Review of systems includes symptoms of rheumatologic, neurological, endocrine, neoplastic, and other systemic diseases;

3.1.2.3 History of smoking, alcohol use, and substance abuse;

3.1.2.4 History of corticosteroid use; and

3.1.2.5 Vocational and recreational pursuits.

3.1.3Physical Examination: Examination of a joint shouldbegin with examination of the uninjured limb and include assessment of the joint above and below the affected area of the injured limb. Physical examinations should include accepted tests as described in textbooks or other references and exam techniques applicable to the joint or region of the body being examined, including:

3.1.3.1 Visual inspection;

3.1.3.1.1 Swelling may indicate joint effusion from trauma, infection or arthritis. Swelling or bruising over ligaments or bones can indicate possible fractures or ligament damage;

3.1.3.2 Palpation for joint line tenderness, effusion, and bone or ligament pain;

3.1.3.2.1 Palpation may be used to assess tissue tone and contour; myofascial trigger points; and may be graded for intensity of pain. Palpation may be further divided into static and motion palpation. Static palpation consists of feeling bony landmarks and soft tissue structures and consistency. Motion palpation is commonly used to assess joint movement patterns and identify joint dysfunction;

3.1.3.3 Assessment of activities of daily living including gait abnormalities, especially after ambulating a distance and difficulties ascending/descending stairs;

3.1.3.3.4 Assessment of activities such as the inability to crouch or stoop, may give important indications of the patient's pathology and restrictions.

3.1.3.4 Range-of-motion and quality-of-motion should be assessed actively and passively;

3.1.3.5 Strength;

3.1.3.6 Joint stability;

3.1.3.7 Hip exam;

3.1.3.7.1 In general, multiple tests are needed to reliably establish a clinical diagnosis. Spinal pathology and groin problems should always be considered and ruled out as a cause of pain for patients with hip symptomatology. The following lists commonly performed tests:

3.1.3.7.1.1 Flexion-Abduction-External Rotation (FABER-aka Patrick's) test is frequently used as a test for sacral pathology;

3.1.3.7.1.2 Log roll test may be used to assess iliofemoral joint laxity;

3.1.3.7.1.3 Ober's is used to test the iliotibial band;

3.1.3.7.1.4 Greater trochanter bursitis is aggravated by external rotation and adduction and resisted hip abduction or external rotation;

3.1.3.7.1.5 Iliopectineal bursitis may be aggravated by stretching the tendon in hip extension;

3.1.3.7.1.6 Internal and external rotation is usually painful in osteoarthritis; and

3.1.3.7.1.7 The maneuvers of flexion, adduction and internal rotation (FADIR) will generally reproduce pain in cases of labral tears and with piriformis strain/irritation.

3.1.3.8 Knee exam;

3.1.3.8.1 In general, multiple tests are needed to reliably establish a clinical diagnosis. The expertise of the physician performing the exam influences the predictability of the exam findings. Providers should be aware that patients with osteoarthritis may have positive pain complaints with various maneuvers based on their osteoarthritis rather than ligamentous or meniscal damage. The following partial list contains commonly performed tests:

3.1.3.8.1.1 Bilateral thigh circumference measurement assesses for quadriceps wasting which may occur soon after a knee injury. The circumferences of both thighs should be documented approximately 15 cm above a reference point, either the joint line or patella.

3.1.3.8.1.2 Anterior Cruciate Ligament tests:

3.1.3.8.1.2.1 Lachman's test;

3.1.3.8.1.2.2 Anterior drawer test;

3.1.3.8.1.2.3 Lateral pivot shift test.

3.1.3.8.1.3 Meniscus tests. Joint line tenderness and effusions are common with acute meniscal tears. Degenerative meniscal tears are fairly common in older patients with degenerative changes and may be asymptomatic.

3.1.3.8.1.3.1 McMurray test;

3.1.3.8.1.3.2 Apley compression test;

3.1.3.8.1.3.3 Medial lateral grind test;

3.1.3.8.1.3.4 Weight-bearing tests - include Thessaly and Ege's test.

3.1.3.8.1.4 Posterior Cruciate Ligament tests:

3.1.3.8.1.4.1 Posterior drawer test;

3.1.3.8.1.4.2 Extension lag may also be measured passively by documenting the heel height difference with the patient prone.

3.1.3.8.1.5 Collateral Ligaments tests:

3.1.3.8.1.5.1 Medial stress test - A positive test in full extension may include both medial collateral ligament and cruciate ligament pathology;

3.1.3.8.1.5.2 Lateral stress test.

3.1.3.8.1.6 Patellar Instability tests:

3.1.3.8.1.6.1 Apprehension test;

3.1.3.8.1.6.2 J sign;

3.1.3.8.1.6.3 Q angle.

3.1.3.9 Foot and ankle exam:

3.1.3.9.1 In general, multiple tests are needed to reliably establish a clinical diagnosis. The expertise of the physician performing the exam influences the predictability of the exam findings. Ankle assessments may include anterior drawer exam, talar tilt test, external rotation stress test, ankle ligament stress test and the tibia-fibula squeeze test. Achilles tendon may be assessed with the Thompson's test. Foot examinations may include, assessment of or for: subtalar, midtarsal, and metatarsal-phalangeal joints; tarsal tunnel; and posterior tibial tendon; Morton's neuroma; the piano key test and Lisfranc injury.

3.1.3.10 If applicable, full neurological exam including muscle atrophy and gait abnormality.

3.1.3.11 If applicable to injury, integrity of distal circulation, sensory, and motor function.

3.2RADIOGRAPHIC IMAGING of the lower extremities is a generally accepted, well-established and widely used diagnostic procedure when specific indications based on history and/or physical examination arepresent. It should not be routinely performed. The mechanism of injury and specific indications for the radiograph should be listed on the request form to aid the radiologist and x-ray technician. For additional specific clinical indications, see Section 5.0, Specific Lower Extremity Injury Diagnosis, Testing and Treatment. Indications for initial imaging include any of the following:

3.2.1 The inability to flex knee to 90 degrees or to transfer weight for four steps at the time of the immediate injury and at the initial visit, regardless of limping;

3.2.2 Bony tenderness on any of the following areas: over the head of the fibula; isolated to the patella; of the lateral or medial malleolus from the tip to the distal 6 cm; at the base of the 5^th metatarsal; or at the navicular;

3.2.3 History of significant trauma, especially blunt trauma or fall from a height;

3.2.4 Age over 55 years;

3.2.5 History or exam suggestive of intravenous drug abuse or osteomyelitis;

3.2.6 Pain with swelling and/or range of motion (ROM) limitation localizing to an area of prior fracture, internal fixation, or joint prosthesis; or

3.2.7 Unexplained or persistent lower extremity pain over two weeks.

3.2.7.1 Occult fractures, especially stress fractures, may not be visible on initial x-ray. A follow-up radiograph, MRI and/or bone scan may be required to make the diagnosis.

3.2.7.2 Weight-bearing radiographs are used to assess osteoarthritis and alignment prior to some surgical procedures.

3.3LABORATORY TESTING Laboratory tests are generally accepted, well-established and widely used procedures. They are, however, rarely indicated at the time of initial evaluation, unless there is suspicion of systemic illness, infection, neoplasia, connective tissue disorder, or underlying arthritis or rheumatologic disorder based on history and/or physical examination. Laboratory tests can provide useful diagnostic information. It is recommended that lab diagnostic procedures be initially considered the responsibility of the workers' compensation carrier to ensure that an accurate diagnosis and treatment plan can be established. Tests include, but are not limited to the following:

3.3.1 Complete blood count (CBC) with differential can detect infection, blood dyscrasias, and medication side effects;

3.3.2 Erythrocyte sedimentation rate, rheumatoid factor, antinuclear antigen (ANA), human leukocyte antigen (HLA), and C-reactive protein (CRP) can be used to detect evidence of a rheumatologic, infection, or connective tissue disorder;

3.3.3 Serum calcium, phosphorous, uric acid, alkaline phosphatase, and acid phosphatase can detect metabolic bone disease;

3.3.4 Liver and kidney function may be performed for prolonged anti-inflammatory use or other medications requiring monitoring; and

3.3.5 Analysis of joint aspiration for bacteria, white cell count, red cell count, fat globules, crystalline birefringence and chemistry to evaluate joint effusion.

3.4OTHER PROCEDURES

3.4.1Joint Aspiration is a generally accepted, well-established and widely used procedure when specifically indicated and performed by individuals properly trained in these techniques. This is true at the initial evaluation when history and/or physical examination are of concern for a septic joint or bursitis and for some acute injuries. Particularly at the knee, aspiration of a large effusion can help to decrease pain and speed functional recovery. Persistent or unexplained effusions may be examined for evidence of infection, rheumatologic, or inflammatory processes. The presence of fat globules in the effusion strongly suggests occult fracture.

3.4.1.1 Risk factors for septic arthritis include joint surgery, knee arthritis, joint replacement, skin infection, diabetes, age greater than 80, immunocompromised states, and rheumatoid arthritis. More than 50% of patients with septic joints have a fever greater than 37.5 degrees centigrade and joint swelling. Synovial white counts of greater than 25,000 and polymorphonuclear cells of at least 90% increase the likelihood of a septic joint.

3.4.2Musculoskeletal Ultrasound. The use of diagnostic ultrasound may be beneficial for guiding injections into the pathologic areas. Ultrasound guided interventional procedure provides the ability to image soft tissues in real time and can improve safety and accuracy of needle placement. The use of ultrasound guided procedures will be at the discretion of the health care provider.

19 Del. Admin. Code § 1342-G-3.0