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Medical records and history questionnaires shall be used only as an adjunct to the history as told by the patient to the physician. The physician shall personally take the history from the injured worker. Any discrepancies in the history between various sources must be identified and clarified. An appropriate history shall include: 
A.      Work history, including previous and current jobs, and some description of previous, and current job duties. Review and comment on a formal job description if it is available for review. Particular attention for the foot and ankle is placed on requirements for standing, walking (over even or uneven surfaces), running, squatting, sitting, kneeling, climbing, jumping, hopping, balancing, lifting, carrying, pushing or pulling with the legs or feet and use of foot controls.  
B.      This section is especially important, as the physician must extract sufficient history to assess the injured worker’s pre-injury functional capacity for work activity. Determining the previous work capacity within the past several years best assesses this. Regular non-work activities can also be taken into account to determine previous functional levels.   
C.      Description of how and when the injury occurred and the type of occupational exposure.  
D.      Summary of the course of treatment for the injured worker since injury includes type of treatment and response to treatment to date.  
E.      Current treatment including type and frequency.  
F.      Description of pertinent past medical history including previous and or subsequent injuries or illnesses, and a description of any prior neurological or musculoskeletal disabilities particularly relating to the lower extremity.  
G.      Pertinent other past medical history and other contributing medical, psychological, or social concerns.  
Current Complaints 
The physician shall outline in the injured worker’s words, his or her current complaints. This shall include all parts affected by the injury or injuries claimed, the character (quality), severity, frequency, and any radiation of symptoms, and what activities or interventions precipitate, aggravate or reduce symptoms. Delineate existing associated signs and symptoms of the injury.  
NOTE: The injured worker’s own description of symptoms shall be “translated” later by the physician into ratable language as defined by Packard Thurber.  
Any subjective complaints regarding work activity or other activities of daily living (ADL’s) shall be outlined in this section. For the foot and ankle, any functional complaints in such as standing, walking (over even or uneven surfaces), running, squatting, sitting, kneeling, climbing, jumping, lifting, carrying, balancing, pushing or pulling with the legs or feet and the use of foot controls shall be listed in this section.  
The use of assistive devices (if any) for mobility such as a wheelchair, cane, or crutches, shall be elicited and described as to type and frequency of use, as well as the need and type of any orthotic or prosthetic devices and special shoes. 
Physical Examination of the Foot and Ankle for Disability Evaluation 
1.      The physical examination shall include relevant description of body habitus, and any general observations such as a limp, obvious discomfort when standing, difficulty in transferring, etc. that may be helpful in determining previous or current functional capacity. Note any assistive devices, prosthetics, orthotics, or shoes that the injured worker uses and describe.  
2.      In all measurements or observations performed, if normal, the physician may simply state “normal”. Describe tests rather than just use an acronym.   
3.      Inspection: The physician shall describe any skin abnormalities, surgical scars, obvious atrophy or skeletal deformities (e.g. angulation of healed fractures, varus or valgus joint deformity, or amputation). The injured parts of the foot or ankle shall be inspected for soft tissue swelling and dislocation.  
4.      Amputations shall be described anatomically.  
5.      Affected areas shall be palpated for tenderness. Any painful areas shall be reported. Any alterations of skin temperature or vascular status shall be noted.  
6.      Joint examination  
a.      The physician shall assess the affected joints and compare them to the uninjured side.  
b.      Joint effusion, enlargement, erythema, and instability shall be described if present. Pertinent clinical tests used in joint assessment (i.e. drawer signs, Thompson’s sign, etc.) shall be described and noted as normal or abnormal. If there is an abnormal range of motion that is not secondary to the injury, give an explanation for this finding.   
c.      Goniometric measurement is the accepted method of evaluation of range of motion for the foot and ankle. A description of goniometric methods of measurement and estimated normal values for the foot and ankle can be found in Packard Thurber, Evaluation of Industrial Disability, Second Edition, Oxford University Press. The physician shall measure active range of motion of all affected joints of the foot and ankle as compared to the uninjured side. Any abnormal, excessive, or limited range of motion or ankylosis shall be described.  
For bilateral injuries estimate the normal range of motion.  Note whether the injured worker gave full effort on active range of motion and if there was any unexplained discrepancies in formally measured versus observed range of motion, or whether limitations in active range of motion was based on pain. If so, list arc range of motion precluded or inhibited by pain. If the measurement obtained were invalid based on lack of effort, so note.  
7.      Leg lengths shall be measured in inches from Anterior Superior Iliac Spine (ASIS) to medial malleolus and if appropriate, other methods of leg length measurement may be included.  
8.      Gait and other functional assessment: Any abnormality of gait shall be described (propulsive vs. apropulsive, angle and base of gait, etc.). Evaluate patient’s ability to squat, stand, kneel, heel and toe walk.   
9.      Neurological examination of the foot or ankle shall be performed for any complaints of weakness, sensory impairment or dysesthesias. This shall include assessment of:  
a.      Motor examination  
i.      Atrophy of specific muscles or muscle groups of the lower extremities or foot should be described. General muscle bulk is assessed by measurements of the calves and thighs in inches. Circumferencial measurements of the foot and ankle should be recorded. Calf measurements are taken at the point of maximum circumference. Thigh circumferences are taken at the point one-third the distance from the upper pole of the patella to the umbilicus.  
ii.      Muscle tone shall be described as increased, normal or decreased.  
iii.      Muscle strength shall be graded using a scale such as those found in Appendix A. Muscle weakness due to neurologic impairment shall be differentiated by the examiner from lack of effort due to pain, disuse or lack of effort due to other causes. In cases of questionable effort, muscle weakness due to neuologic deficit can generally be corroborated by appropriate electodiagnostic testing including needle EMG and a nerve conduction study performed by an appropriately qualified physician.  
b.      Sensory examination shall include a screening of touch and pain sensation (pinprick) in pertinent foot, ankle and lower extremity dermatomes/peripheral nerve distributions and of joint proprioception of any involved joints. Any abnormalities shall be described fully and correlated with peripheral nerve or dermatomal pattern. If the pattern of sensory impairment is nonphysiological, this should be noted  
c.      Deep tendon reflexes shall be obtained and graded as 0 (absent) to 4+ (hyperactive with clonus). Plantar responses and any other abnormal reflex responses shall be recorded.  
d.      Coordination shall be assessed if this is a presenting complaint, or if there is suspicion of foot, ankle or lower extremity motor coordination impairment. In this case, finger to nose, heel to shin and gait should be described.  
viii. Screening exam of the remainder of the neurological or musculoskeletal system if there is any evidence of more widespread involvement. 
F. Diagnostic Studies in Lower Extremity Disability Evaluation 
1.      Order diagnostic studies only when the studies may alter the recommended plan or the evaluator's opinion regarding factors of disability. The evaluator must document the need for these additional studies.  
2.      List any diagnostic procedures performed, as well as the dates and the results of the procedures. Provide the name, specialty, qualifications and opinion of any consultants.  
3.      Methods of Assessment  
a. Clinical diagnosis of foot and ankle problems can usually be made on history and physical examination with the help of x-rays. 
b. In addition to an x-ray, testing may include: 
i. MRI 
ii. CT 
iii. Bone Scan 
iv. Arthogram 
v. Use of mechanical devices to test strength and stability. 
vi. EMG/NCV testing is appropriate only if there is a suggestion of nerve damage or nerve compression. 
vii. Vascular studies are indicated only if there is associated vascular disruption/damage or a secondary vascular complication. 
viii. Blood studies 
ix. Ultrasound 
Appendix B 
Subjective disability should be described in terms of location, degree, frequency, and precipitating activity. Terms describing degree and frequency are taken to have the following meanings: 
Minimal or mild pain constitutes an annoyance, but causes no handicap in the performance of activity. 
Slight pain can be tolerated but causes some handicap in the performance of precipitating activity. 
Moderate pain can be tolerated but causes marked handicap in the performance of precipitating activity. 
Severe pain precludes precipitating activity 
Occasional — approximately 25% of the time 
Intermittent — approximately 50% of the time 
Frequent — approximately 75% of the time 
Constant — approximately 100% of the time 
Authority cited: Sections 139, 139.2, 4060, 4061 and 4062, Labor Code. 
Reference: Sections 139, 139.2, 4060, 4061, 4061.5 and 4062, Labor Code 
Appendix C 
Maintaining body equilibrium
Angulation from neutral position about a joint (e.g. ankle) or spine (e. g. forward)
Transporting an object, usually holding it in the hands or arms or on the shoulder.
Ascending or descending ladders, stairs, scaffolding, ramps, poles, etc. . . using feet and legs and/or hands and arms.
Moving about on hands and knees and feet.
Bending body downward and forward by bending lower limbs, pelvis and spine
Moving about suddenly by use of leg muscle, leaping from or onto the ground or from one object to another.
Bending legs at knees to come to rest on knee or knees.
Raising or lowering an object from one level to another (includes upward pulling.)
Planting your foot and turning about that point.
Exerting force upon an object so that the object moves away from the force (includes slapping, striking, kicking and treadle actions).
Exerting force upon an object so that the object moves towards the force (includes jerking).
Moving in a fast pace, moving the legs rapidly so that for a moment both legs are off the ground.
Remaining in the normal seated position.
Crouching to sit on your heels, with knees bent and weight on the balls of your feet.
Remaining on one's feet in an upright position at a work station without moving about.
Bending body downward and forward by bending spine at waist.
Moving about a central axis, revolve or rotate.
Required to control a machine by use of controls.
Moving about at a moderate pace over even or uneven ground.
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