O'Donohue's "Terrible Triad"

Mechanics

The anterior cruciate is the main factor causing resistance to the anterior displacement of the tibia on the femur. This is demonstrated when the orthopedic surgeon pulls the tibia forward on the femur performing a test of the anterior cruciate ligament. The tibia will displace much further forward than it should when the ACL is torn. The ligament is tight when the knee is in full extension and has the least amount of tension at approximately 45’ of flexion. Because there are different bands to the anterior cruciate ligament different areas of the anterior cruciate tighten at different angles of the knee.

Physical Examination

Examination immediately at the time of injury will reveal usually at least mild swelling of the knee, but not necessarily. The best test is called a Lachman Test where each of the examiner’s hands are placed just above and just below the knee joint. The lower bone is brought forward with the knee angled at approximately 15’ and the examiner assess the end point. Usually, there is a firm endpoint with an intact ACL when the tibia is pulled forward. When the ligament is torn that endpoint is no longer present. The examiner will also look for increased excursion of the tibia forward on the femur. A Drawer Test is when the knee is flexed to 90’. Essentially, the same test is performed. It is more difficult in an acute situation to perform this test because usually the athlete’s knee is too sore to allow the knee to bend to 90’. A Pivot Shift is a test where the knee is brought from an extended position into flexion. Usually the knee will show a slight and subtle shift as the tibia rotates on the femur and shifts back into proper position. It is actually subflexed in the full extended knee position and returns to its natural position as the knee is flexed. As it returns to its natural position there is a "pivot shift" which takes experience to detect.

Associated injuries are always assessed for at the same time. Joint line tenderness representing torn cartilage and tenderness over the lateral knee which may reflect tearing of the collateral ligaments. O’Donohue’s "terrible triad" injury involves not only the ACL, but also the medial meniscus and the medial collateral ligament. It is unfortunately fairly common.

Treatment of Foot Problems Pt.3

Hammertoes

A muscle imbalance or abnormal bone length can make one or more small toes buckle under, causing their joints to contract.  This in turn, causes the tendons to shorten.  Corns (build-ups of dead skin cells where shoes press and rub) often form on the contracted joint, and may become irritated and infected.

Flexible Hammertoes

When hammertoes are flexible, you can straighten the buckled joint with your hand.  Flexible hammertoes may progress to rigid hammertoes over time.  Corns, irritation, and pain are common symptoms.   Function is often limited as well.

Rigid Hammertoes

A rigid hammertoe is fixed; you can no longer straighten the buckled joint with your hand.  Corns, irritation, pain, and loss of function may be more severe for rigid hammertoes than for flexible ones.

Curled Fifth Toe

The little toe may curl inward underneath its neighbor so that the nail faces outward.  With this inherited problem, the fat pad on the bottom of the toe (normally used for walking) loses contact with the ground.  Corns and pain may result.

Plantar Calluses

Second Metatarsal Plantar Callus

When the second metatarsal bone is longer or lower than the others, it hits the ground first - and with more force than it is equipped to handle at every step.  As a result, the skin under this bone thickens.   Like a rock in your shoe, the callus causes irritation and pain.  The treatment for this is an osteotomy.  The second metatarsal bone is cut, and the end of the bone is then "lifted" and aligned with the other bones.

Heel Spurs

A heel spur is a bony overgrowth on your heel bone (see Plantar Fascitis).  It may be stimulated by muscles that pull from the heel bone along the bottom of the foot.  High-arched feet are especially apt to have too-tight muscles here.  Heel spurs may cause pain  when the foot bears weight.  They can be treated first with an injection, anti-inflammatory medication, as well as arch supports if indicated.  If this fails, they can then be treated with surgical excision and a plantar release.  The band of tight muscles is released to relieve the abnormal stress.  The bone spur is surgically removed.

Neuromas

When a nerve is pinched between two metatarsal bones (usually the third and forth metatarsals), enlargement of the nerve may occur.  Abnormal bone structure contributes to the cause, but too-tight shoes can aggravate the condition.  You may experience sharp pain in your toes that may become severe enough to keep you from walking.

Treatment

Excision: A small portion of the nerve is removed.  As a result of this, a small area is usually permanently numbered, but this is preferable to pain.

Follow-up Care

You can usually bear weight right away, but you must return to have your dressing changed.  Keep your incision dry until the stitches are removed.

High-Arched Feet (Pes Cavus)

The shape of your foot often determines the kinds of foot problems you will have.  Your feet may have unusually high arches due to an imbalance of muscles and nerves, which is usually inherited.   Too high arches can cause various problems - tired or aching feet; and calluses.   High arches are not usually investigated with surgery but most often treated with arch supports.

Flat Feet (Pes Planus)

Flat feet can be hereditary and are caused by a muscle imbalance.  Feet with low, relaxed arches may bring on such problems as hammertoes and bunions; arch, foot, and leg fatigue; calf pain; and an overly tight heel cord (which makes the foot even flatter).  Loose joints move to freely, causing pain and instability.  Flat feet are also usually treated with arch supports.

Orthotics

Orthotics (also called orthoses or orthotic devices) are prescribed, custom0made arch supports.  They fit inside most shoes and "bring the floor up to your feet."

A podiatrist may prescribe them to help correct such problems as high arches and flat feet.  Also, following some foot surgeries, orthotics can help support the correction that was achieved.

To be fitted with orthotics, your podiatrist will first take an impression of your feet.  Your orthotics are then fashioned from leather, plastic, or other materials.  Their fit is checked at an office visit and adjustments can be made as you wear them.  Expect an initial "breaking-in" period; you may need to build up wearing time gradually (as you would with contact lenses).

Surgery Decision

If your bunions or hammertoes are bad enough, they may need surgical correction.  This is a gratifying operation that can provide both pain relief and improved appearance.

Risks

All surgery carries risks including stiffness, persistent pain and swelling, recurrence of problem, damage to nerves, hardware breakage, blood clots in the legs, anesthetic problems, inability to correct the problem, etc.  Make sure you understand the risks and alternatives prior to surgery.

Post-Operative Tips

Your recovery, like your foot problem and surgery, is as unique as you are.  In addition to the previous tips given on follow-up care for each surgery, here are some pointers that can help you recover quickly and without complications, and help get you back on your feet again.

Pain:  To help relive pain and reduce swelling in the first 24 to 48 hours after surgery, apply an ice pack to the affected area and elevate your foot above heart level, as recommended.  Pain is usually most severe the second and third days after surgery, and after you first begin to walk again.

Bathing:  You will need to keep your foot dry.  Getting the stitches wet can lead to infection, so be sure to keep your foot outside the shower or bath.

Weight-Bearing:  Bearing weight and walking can stimulate circulation and promote healing.  But overtaxing a healthy foot can detract from the results of your surgery.

Shoes:  Our team may give you a wide surgical shoe to wear on the affected foot.  A surgical shoe stabilizes and protects the foot as it heals.

Returning to Work: How soon you can return to work depends on the type of surgery you had and the activities you job requires.  You can generally return earlier to a desk job than to physical labor.   Consider beforehand how much time you can take off from work until you are back on your feet.

REPORT TO EMERGENCY IMMEDIATELY IF YOU NOTICE REDNESS, DRAINAGE, INFECTION, CALF PAIN, SHORTNESS OF BREATH, OR HAVE ANY CONCERNS.

TREATMENT OF FOOT PROBLEMS

TREATMENT OF FOOT PROBLEMS

Reasons for Foot Surgery

The more you know about what to expect, the more smoothly your treatment, either conservative or surgical, is likely to be.  While each problem is unique, there are three basic goals: to relieve pain, to restore function, or to improve the appearance of your feet.

Relieve Pain

Feet that hurt interfere with your work, family, and your social life.  Pain often signals an underlying problem.   Fortunately, in many cases, foot treatment can correct the problem and relieve the pain.

Restore Function

If your feet are not doing their job, it is hard for you to do yours.  When simply walking becomes a problem, your lifestyle is affected.  But accepting a life of hobbling or sitting on the sidelines can make you old before your time.  Foot surgery can be performed at almost any age - and in most cases, surgery can restore the normal use of your feet.

Improve Appearance

Although foot surgery is not usually performed for cosmetic reasons alone, it can often improve the appearance of your feet.

Information on Bunions

BUNIONS What is it? A bunion is a very common foot deformity that develops over the first metatarsal phalageal joint of the big toe of the foot. The joint that joins the big toe to the foot is called the first MTP joint. When it becomes prominent and the big toe starts to become crooked this is known as a bunion. The term referring to deformity of the big toe as it becomes crooked is called Hallux Valgus. It is the bump itself that is known as the bunion. When it gets red and swollen over the bunion because it gets sore this is usually due to an inflamed soft tissue over the underlying bone. Causes The commonest cause of bunions is prolonged wearing of poorly designed shoes such as the narrow high heels that women wear. This is one of the reasons why bunions are much more common in women than in men. There is also a hereditary component to bunions in that many times we will see a grandmother, mother and daughter all with various stages of bunions. 38% of women in the United States wear shoes that are too small and 55% of women have some degree of bunion formation. Bunions are 9 times more common in women than they are in men. History Left untreated bunions will gradually become worse especially if women continue to wear the narrow pointed shoes. Not all bunions progress because if the patient starts wearing good shoewear and they are caught early enough they may not get any worse. In general however, they will certainly not get any better no matter how they are treated. We generally reserve surgical treatment for bunions that are painful. If they are not painful they should simply be observed and shoewear modified. Occasionally the patient will want the bunion corrected for cosmetic reasons.

The Economic Burden of WAD

THE ECONOMIC BURDEN OF WAD

Little is known about the individual and societal economic burden of WAD. For instance, little is known about the prevalence of long-lasting work disability due to WAD, which probably the most costly part. This burden is probably largely dependent on the legislation in different countries. In 2002, an independent and temporary Commission on whiplash-related injuries was informed in Sweden, initiated by the four largest motor vehicle insurers. The mandate of the 3-year commission was an examination of the problems of WAD from road safety, medical care, insurance and societal aspects. One of the conclusions of the final report was that the yearly cost for society and for the insurance industry was approximately SEK 1.5 billion (US$201million), while projected costs (i.e. what new cases of WAD arising in a particular year will cost society and insurers by the time the person reaches retirement age) amounted to SEK 4.6 billion (US$648 million). These calculations were based on an annual incidence of 30,000 WAD cases (324 per 100,000 inhabitants) in the year 2002. Since the report’s publication, the number of WAD cases have decreased dramatically to about 16,000 claims in 2008 (173 per 100,000 inhabitants), which, of course, has an impact on the overall costs.

Comparable data has not been found, but there is some evidence from a study that addressed the incidence of WAD in 10 European countries. The administrative data suggests that the total claims cost in Switzerland was 500 million Swiss francs (US$467 million). Switzerland’s population is 80% that of Sweden. Expenditures in addition to the claims cost was not reported in that study. 

WAD and Widespread Pain

WAD and Widespread Pain

One important aspect about the course of recovery from WAD is whether the neck injury is a trigger for subsequent widespread body pain. This has been suggested from cross-sectional studies, but knowing whether widespread pain came before the neck injury remains unclear from this type of study design. A potential aetiological explanation is a neurophysiological disturbance in the peripheral and central nervous system, which, in some stances, leads to an increased sensitivity to pain in other ‘uninjured’ areas. Another possible explanation for widespread pain is that new tissue damage may result from an altered pattern of movement in the body due to the neck pain. The exact aetiology of widespread pain is that new tissue damage may result from an altered pattern of movement in the body due to the neck pain. The exact aetiology of widespread pain is probably complex and multifactorial, but there are no indications that it would be specific to WAD. It can also occur after surgical intervention or any tissue damage. In addition, large prospective studies on pain of other aetiology have demonstrated that psychosocial factors at work, repetitive strains or other physical strains at work, awareness of symptoms and illness behavior may increase the risk of development of widespread pain. Thus, it seems that biological as well as psychological and social factors contribute to the development of widespread pain.

Prospective studies on WAD and its association with widespread pain are sparse and the evidence is not clear. The results from one study suggest a relationship between the onset of neck pain or other associated symptoms as well as self-perceived injury severity, after an MVC, and subsequent widespread pain. However, age, gender, health behavior and somatic symptoms prior to collision were at least as important. Another study investigated the incidence of onset of more extensive pain during 12 months of follow- up of WAD claimants, and associated factors with such an outcome. In that study, a less conservative definition of widespread pain was used and probably have resulted in higher incidences. The main conclusions were that widespread pain was common over a 12-month period (21%), but most improved over the follow- up period. Female gender, poor prior health, greater initial symptomatology (including pain intensity) and more depressive symptoms were associated with the development of extensive pain. The authors also found that local neck/ back pain, raising the question of the potential cause of widespread pain in other studies.

Specificity of Association and Apportionment

Specificity of Association and Apportionment

Most medical conditions are multifactor in etiology; ie, they are reflective of more than one physiologic or environmental process. Evaluation of the results of epidemiologic studies via regression analysis (which weighs the contribution of various factors both individually and the combination on a given event or events) provides data that can be applied when reaching conclusions regarding the degree to which one would expect a given factor to contribute to the medical condition under evaluation but never can provide definitive answers regarding apportionment.

               It is impossible to accurately evaluate to what extent a given factor or exposure was the contributing cause in a multifactorial disease process. Likewise, in certain situations (such as heart disease), the genetic predisposition of the affected individual is a considerable, if not primary, determinant of causality. Assessing the specificity of association is consequently often the most difficult aspect of causality analysis.

               There is a great deal of legal terminology focused on establishing, and labeling, the degree to which an event or injury has led to a particular outcome. The legal determination of causality uses, but does not necessarily rely upon, the medical evidence that supports or refutes a casual relationship between a given event and outcome. Furthermore, it is often societal decision, and not scientifically required to reach conclusions about the presence or absence of a casual relationship. Using the legal definitions of causality, a relationship between an event and a given outcome is classified as “probably” or “possible.” It is probable if the chance of them being related is greater than 50%. It is possible if the chance of a relationship is deemed to be less than 50%. The skill of the attorneys arguing the case, the credibility of the claimant and his or her physician, the ability of the medical expert to present the medical information regarding causality, and the existence of case law (which may have established the de facto existence of a casual relationship unless definitively proven otherwise) all influence the ultimate determination. Statements are often made regarding the probability or possibility of a causal relationship between an event and an outcome in the absence of an objective epidemiologic or biologic rationale for the determination. While the Supreme Court, in Daubert case, held that testimony must be grounded in the methods and procedures of science and based on more than simply subjective belief or unsupported speculation to be held as relevant and reliable, this standard is not routinely used in many jurisdictions. Thus the use of the legal terminology alone can imply a degree of certainty that may be completely unfounded. 

Spinal Dysfunction

Spinal Dysfunction

Lumbosacral Spine

Because back pain is the second leading cause of work absenteeism and the number one cause of Workers’ Compensation claims, it is important to understand the appropriate role of radiologic imaging in the assessment of spinal dysfunction. The goal of any imaging study is to define accurately the path morphologic changes in a specific tissue, organ, or part of the body. Objective categorization of pathologic changes facilitates the interpretation and communication of abnormalities detected on a test, and these same criteria can be used on follow-up evaluation to assess the effects of different forms of therapy (eg, surgical intervention or non-operative rehabilitation). The reproducibility and the reliability of all objective diagnostic criteria must be rigorously evaluated in prospective blinded studies prior to their implementation.

               Patients with neck or low-back pain (LBP) are a challenge to the physician who desires a precise patho-anatomic diagnosis prior to the initiation of therapy. Back pain and neural dysfunction are a frequent symptom complex for many processes afflicting the lumbar spine and Paraspinal tissues. For this reason, a clinical assessing a patient after a work-related injury must consider and exclude a large number of potential causes to explain a patient’s symptoms. Fortunately, most episodes of back pain are self-limited, and diagnostic tests are needed. However, if pain persists or becomes worse, it is usually necessary to order a diagnostic test to provide the additional clinical information needed to choose rationally the appropriate therapeutic modality. Prior to ordering any diagnostic test, a clinician must determine how the information provided by the test will affect patient management and mentally compare projected test costs and expected benefits. The more precise the information provided by a diagnostic test, the greater will be its impact on directing patient care. The value of different tests depends on their sensitivity, specificity, accuracy, risk, cost, and availability.

Persistent Pain as a Disease Entity

Persistent Pain as a Disease Entity

Persistent pain is a major health problem, with between 18% and 50% of the population reporting continuous pain for at least 3 of the last 6 months. Chronic pain has been linked with significant disability. Although pain has been traditionally regarded as a symptom that serves as a warning signal of an underlying disease process, there is accumulating evidence that persistent pain should be considered a disease entity in its own right. Indeed, permanent changes in the responsiveness of both the peripheral and centralnervous systems can persist even after all tissue healing has ensued; thus, persistent pain can become a self-perpetuating condition. The individual is signs of original inciting disease process that initiated the pain. This results in a multitude of consequences that can lead to significant impairment for the individual affected, including physical impairment, mood dysfunction, and social disruption. This is in keeping with the earlier biopsychosocial perspective of CPS.

How Much Weight Should Be Given To Pain in Impairment Ratings?

How Much Weight Should Be Given To Pain in Impairment Ratings?

Whether or not to include PRI in the Guides can be frames as a qualitative yes or no question. However, it is more fruitful to from the issue in quantitative terms by asking the following question: How much weight should be given to pain in impairment ratings? Opponents of PRI, in effect, argue that pain (and other subjective factors) should be given zero weight, so that impairment ratings reflect only objective factors. Many proponents of including PRI in the Guides argue not only that pain should considered in impairments ratings but also that a PRI system should permit patients with severe pain to receive impairment awards with high WPI percentages. An impairment rating system could make a “cautious foray into the difficult waters” of PRI assessment by permitting awards to be made for PRI, but capping these awards at a modest level. This describes the strategy used in the Guides’ Fifth Edition, in which PRI capped at 3% WPI. In the absence of persuasive empirical research on the extent to which pain affects the ability of people with medical conditions to function or the measurement problems that arise when PRI is assessed, any dcision about caps for PRI will be perceived as arbitrary. 

Crucial Issues

Crucial Issues

In our opinion, the most powerful arguments against the inclusion of PRI in the Guides are that (1) PRI assessments are likely to be unreliable and (2) they might lead to systematic errors in assessment, such that persuasive patients can “game the system” and get inappropriately high impairment awards. Both of these arguments derive from the permise that it is very difficult for examiners to determine the extent to which patients are affected by their pain. These difficulties were succinctly captured by Scarry when she said: “To have great pain is to have certainty; to hear that another person has pain is to have doubt.” The problem of reliability and validity of PRI assessment is much more than an academic problem in measurement theory. The Guides serves the societal role of providing the equitable method of compensation individuals who ability to function has been compromised by a medical condition. For the Guides must employ assessment procedures that are reliable and valid, rather than capricious ones that can be manipulated by persuasive patients. Thus, regardless of how severely pain affects individuals with various medical conditions, a PRI assessment system must have reasonable reliability and validity to accomplish the societal goal of fairly compensating them.

In fact, the key issue separating proponents and opponents of impairment due to pain is the weight they place on ease of measurement of PRI vs. relevance of PRI. Advocates for PRI emphasize that pain has great relevance to the ability to function of individuals who have various medical conditions, but these advocates tend to downplay the problems of measuring PRI. Opponents tend to emphasize problems in measurement but ignore the issue of relevance. In principle, empirical research could be performed to determine the strength of the independent contribution that pain makes to the burden of illness borne by individuals with various medical condition, and whether examiners can reliably and validly assess PRI. Considerable research has been done on the first issue, at least for some common painful conditions such as disorders of the lumbar spine. Unfortunately, though, essentially no research has been done on the issue of determining the reliability and validity of PRI assessments. Construct validation research is greatly needed in this area. At this time, as a practical matter, decisions regarding PRI for purposes of the Guides’ Sixth Edition must be based on judgment rather than empirical data.

Chronic Pain Syndrome

Chronic Pain Syndrome

In both the Fourth and Fifth Editions of the Guides, a definition of chronic pain syndrome (CPS) was included that captured the major biopsychosocial characteristics of chronic pain. Indeed, the biopsychosocial approach to chronic pain and disability is currently viewed as the most heuristic perspective to the understanding, assessment, and treatment of chronic pain disorders, and has replaced the outdated biomedical reductionist perspective. This biopsychosocial approach views chronic pain as a complex and dynamic interaction among biological, psychosocial, and social factors that perpetuates, and may even worsen, the clinical presentation. Each person will experience a chronic pain condition uniquely, this accounting for the great individual difference in how pain is expressed. The complexity of a chronic pain disorder is especially evident when it persists over time, as a range of psychosocial and economic factors can interact with pathophysiology to modulate a patient’s report of discomfort and disability healing occurs, all patients experience some degree of physical deconditioning associated with stiffness and muscle atrophy in the injured area. Risk factors for profound deconditioning with the injured area becoming a “weak link” include extended periods of inactivity, inhibition of function due to pain, and fear avoidance. In striking contrast, the traditional and outdated biomedical approach assumes that all pain symptoms have specific physical causes, and attempts to eradicate the cause directly by identifying and rectifying the presumed pathophysiology. However, chronic pain can rarely be understood by the linear, nociceptive mechanism. As will be discussed later in this chapter, there is often an absence of a document-able relationship between pain and pathophysiology.

With the above biopsychosocial perspective in mind, CPS can be described as pain that continues beyond the normal healing time for the patient’s diagnosis and includes significant psychosocial dysfunction. It should be noted that this definition does not include any specific time frame to use in making the diagnosis of CPS. This omission is intentional and reflects clinical reality, in that some conditions would be expected to resolve in several days and others in several months or even years. The diagnosis of CPS should then be temporally connected to the point at which a given condition or conditions were expected to have resolved, rather than to any arbitrary time period for an injury or event. Regardless of when it occurs, CPS is a condition that ultimately adversely affects the patient’s well being, level of function, and quality of life. The major characteristics associated with CPS include the following with 3 or more required for a diagnosis:

Ÿ  Use of prescription drugs beyond the recommended duration and/or abuse of or dependence on prescription drugs or other substances.

Ÿ  Excessive dependence on health care providers, spouse, or family.

Ÿ  Secondary physical deconditioning due to disuse and/or fear-avoidance of physical activity due to pain.

Ÿ  Withdrawal from social milieu, including work, recreation, or other social contacts.

Ÿ  Failure to restore pre-injury function after a period of disability, such that the physical capacity is insufficient to pursue work, family, or recreational needs.

Ÿ  Development of psychosocial sequelae after that initial incident, including anxiety, fear-avoidance, depression, or nonorganic illness behaviors.

Definition of Pain

Definition of Pain

The International Association Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” Pain is a prominent symptom in many acute injuries and illnesses, and often subsides as the medical condition resolves. Since such acute pain is usually short lived, it is not a problem that is considered in an impairment rating system. However, chronic pain is a problem that potentially could be the cause for an impairment rating. The definition of chronic pain is imprecise but, in a general way, it refers to pain that persists over time. For the purposes of the Guides, chronic pain is defined as pain that persists beyond the expected healing time of the medical disorder thought to have initiated the pain. For many sections inthe Guides, chronic pain will be pain that persists beyond 3 months, as most common conditions affecting the musculoskeletal and other organ and systems will substantially heal in this time frame. The nervous system is a notable exception. Although any time point is arbitrary, 3 months should encompass the expected healing time in most situations where there is tissue injury but will allow for situations in which there is no expected healing time. 

Fundamentals

Fundamentals

Medical causality is imputed when the association between a medical condition and a given exposure (physical, biologic, or chemical) is such as to lead one to believe that the condition would not have occurred in the absence of the exposure. The temporal relationship between the exposure or injury and the medical condition (or symptoms suggestive of the condition) is the first factor that must be assessed. The illness or disease should occur after the exposure (referred to as “temporal ordering”) and within a time period that is reasonable given the nature of the exposure (temporalcontiguity). In certain situations (such as asbestos, lead, and benzene exposure) there is a long latency between the time of exposure and the appearance of disease. Hence, regardless of whether a temporal relationship appears to be present, determining causality also requires one to assess whether a causal relationship is biologically plausible.

               A causal relationship is biologically plausible when:

               1. The relationship between the medical condition and the exposure or injury can be explained anatomically or physiologically.

               2. The duration, intensity, or mechanism of exposure or injury was sufficient to cause the illness or injury in question.

               3. There is evidence suggesting that the exposure is consistently or reliably associated with the process under investigation in the population under investigation or in peer-reviewed literature.

               4. Cause and effect are contiguous--ie, there is a readily understandable relationship between the two, in which an increase in the magnitude of the exposure reliably leads to an increase in the severity of its alleged effect upon the injured or exposed person, and vice versa.

               5. There is literature providing biologic or statistical evidence indicating that the symptoms or disorder could develop as a result of the exposure (coherence).

               6. There is specificity of the association for the injury (ie, the absence of other factors, especially pre-existing disease, that could have caused or contributed to the problem).

               The independent examiner is obligated to evaluate the validity and strength of all postulated causal mechanism. Mechanisms that appear weak, or are clearly flawed, must be identified as such and accepted as likely only when at least two other criteria for biologic plausibility have been met. Optimally one would wish to satisfy all criteria. There are, however, circumstances when contiguity cannot be demonstrated, as some exposures lead to disease in a noncontiguous fashion. Specificity of association is also difficult to illustrate definitively given the multifactor nature of many disease processes. Literature supportive of causality is generally available, but must be closely scrutinized before relying upon it as it is often poor quality.

Muscle Strains

Muscle Strains

Muscle strains are probably the most common type of injury to the myotendinous unit (MTU). A muscle strain is an acute stretch-induced injury secondary to excessive indirect force generated by eccentric muscular contraction. Muscle strains may occur anywhere in the body, but the most frequent muscles involved are the quadriceps femoris, biceps femoris, semimembranosus, semitendinosis, and gastronomies-soleus complex. Muscles that cross two joints and have a high proportion of fast twitch fibers are more prone to muscles stabilizing the hip, shoulder, and elbow joints. The pain elicited from an acute muscle strain is typically experienced during an athletic activity or immediately at its termination. The pathologic changes in an acutely strained muscle include disruption of the muscle fibers near the myotendinous junction along with edema and hemorrhage. The grade of a muscle strain depends on the degree of fiber disruption and the clinical findings.

               The appearance of a grade 1 muscle strain on MRI is similar to the findings of a grade 1 muscle contusion. There may be enlargement of the muscle due to interstitial edema and hemorrhage and, on a spin-echo T2-weighted or STIR sequence, there will be increased signal intensity within the muscle. Muscle strains are frequently located near the muscle’s myotendinous junction. The tendon of a multipennate muscle extends into the muscle belly; therefore, the symptoms elicited by a strain may be located anywhere within a muscle and not merely at its ends. MRI has provided excellent documentation of the extent and position of these injuries. Fleckenstein et al reported on the MRI appearance of the natural history of acute muscle strains. Acutely, the abnormal signal intensity was identified throughout the muscle, but on follow-up studies the abnormal signal intensity was most prominent in the periphery of the muscle. In one patient there was persistent abnormal signal intensity within the muscle after complete resolution of symptoms.

               A grade2 muscle strain manifests clinically as muscle pain associated with a loss of strength. Pathologically there is a macroscopic partial tear of the MTU. On an MRI study, there will be a partial tear of the muscle fibers associated with edema and/or hemorrhage. With a grade 3 strain there is a complete disruption of the MTU. Plain films provide little useful information in the evaluation of most muscle strains. Only if there is a grade 3 strain that results in gross instability or malalignment (e.g., a quadriceps rupture) will plain films be helpful. CT has also been used to evaluate muscular strain injuries, but it provides less useful clinical information compared to an MRI examination.

               In addition to the evaluation of acute or delayed muscle injuries, MRI is an ideal imaging modality to follow the evolution of the inflammatory and reparative processes within a muscle. With MRI it is possible to detect any sequelae from a MTU injury (e.g., muscle atrophy or fibrosis). Clinically it can be extremely difficult to determine when a muscle has completely healed, and if an athlete or worker returns to his or her athletic activity or job too soon after injury, he or she may be predisposed to repeat injury. MRI has detected acute MTU injuries that were superimposed on sub acute or chronic injuries that may be predisposed the muscle to reinjury.

Muscle Injuries

Muscle Injuries

Muscle Contusions and Tears

Muscle injuries may result from a direct or indirect application of force to the muscle. A direct blow to a muscle may cause a muscle contusion with disruption of muscle fibers. Acute disruption of muscle fibers and capillaries may precipitate soft tissue hemorrhage and a hematoma along with a secondary inflammatory response. With the acute pain associated with muscle injury, it may be difficult on a physical examination to determine the precise location, extent, and severity of an injury. Prior to the implementation of MRI, radiologic imaging studies were of little value in the evaluation of acute muscle injuries. On plain films there may be obscuration of the fat planes surrounding an injured muscle secondary to the perimuscular edema. With CT there may be an alteration of the size or contour of a muscle but detection of intramuscular hemorrhage, edema, or a hematoma is difficult. With the excellent soft tissue contrast resolution provided by MRI, it is now possible to obtain the following important clinical information related to a muscle injury: (1) the extent of muscle edema and/or hemorrhage; (2) is a focal hematoma is present, including its size and location; (3) the degree and extent of muscle fiber disruption; (4) if there is complete disruption of the muscle, whether there is associated muscle retraction; (5) whether there is interruption of the overlying fascia and if there is a muscle herniation; (6) the degree of muscle swelling and the detection of a possible concomitant compartment syndrome; and (7) whether single or multiple muscles are injured. Muscle contusions occur most frequently in the lower extremities, particularly involving the quadriceps mechanism.

               On an MRI examination, a muscle contusion is detected by abnormal signal intensity and morphology of the muscle. On spin-echo sequences, normal muscle demonstrates intermediate signal intensity on T1-weighted sequences and intermediate to low signal intensity on T20weighted sequences. Because hemorrhage infiltrates through the muscle, and mixes with the interstitial edema, it is not possible to separate it from the edematous muscle tissue. With a grade 1 contusion (i.e., microstructural fiber failure) there may be a slight increase in the size of the muscle and the margins of the muscle may have a feathery appearance due to the extension of interstitial edema into the perimuscular tissue. Edematous changes in the adjacent subcutaneous fat are also frequently detected. With a grade 2 muscle contusion (ie, partial tear) there will be a focus of disrupted muscle fibers in addition to the altered signal intensity from the interstitial edema and hemorrhage. A grade 3 muscle contusion will appear similar to a grade 2 contusion, except there will be complete disruption of the muscle fibers. With a muscle hematoma, there will be a focal accumulation of blood within a muscle. A hematoma demonstrates intermediate or high signal intensity on a T1-weighted sequence, depending on the chemical composition of the hematoma, and high signal intensity on a T2-weighted sequence. The sequelae of a muscle contusion may include muscle atrophy, fibrosis, calcification, or ossification.

             

Causality Assessment

Causality Assessment

Before making any impairment or disability determination, the physician is obligated to understand how an organ system (or body part under study) normally functions in the absence of disease. This is then coupled with a thorough understanding of the mechanism of the disease process under investigation. Causality is possible--ie, biologically plausible--if the nature of the adverse effects produced by a given physical, chemical, biologic, or psychological stressor is sufficient to alter the anatomy or physiology of the system or body part involved in a fashion that results in the disease under investigation. There also must be an appropriate temporal relationship between the alleged causal event and the disease manifestations. Furthermore, in situations where there is trauma, the mechanical forces involved must be sufficient to cause the alleged physiologic or anatomic stress.

               One should then look for studies supporting the causal relationship between the type of exposure or injury the claimant sustained and the disease process or injury under investigation in the medical literature. If they exist, the next step is to assess whether the epidemiologic and statistical principles used in these studies suggest that the causal association is real, or whether these studies are merely anecdotal or otherwise without scientific basis or validity. If the association between an exposure or injury and the postulated “effect” meets epidemiologic, physiological, and mechanistic criteria for imputing causality, or the injury is a clear sequela of direct trauma, it is then reasonable to assume that a causal relationship between an alleged exposure or injury and the disease process actually exists.

               These types of determinations must not be made solely on the basis of the claimant’s history. The medical records provide a more accurate and defensible history and must support the occurrence of the injury and the appearance of symptoms orsigns of pathology within a time frame that is consistent with the disease process under investigation. Those records from immediately after the injury are best for this purpose, as they are regarding the claimant’s status both before and after a trauma, and often provide the most accurate description of what actually occurred. Emergency room records, police and accident reports, and the employer’s report of occupational injury or disease (for workers’ compensation claims) are examples of documents that are particularly useful in this regard. If these records are not available or are ambiguous, it is best to describe the assessment of causality as provisional rather than definitive, even if the mechanism of injury, the physical examination, and the literature review indicate that a causal relationship may indeed be present.

               Combinations of direct trauma and a preexisting disease process are more difficult to assess for causality and apportionment. One must determine, again, if the requirements of temporal relationship, biologic plausibility, literature support, and sufficient injury have been met. This includes an assessment of whether the trauma would have caused the disease in the absence of the preexisting process or whether the injuries caused by the trauma or whether the injuries caused by the trauma or exposure would ordinarily decrease over time, because these answers provide grounds for apportionment. It is equally important to assess whether the trauma would have progressed on its own accord to a point where the claimant would have has the same clinical presentation; if so, one can argue that the accident only caused an acceleration of an inevitable process.

               When dealing with preexisting conditions, it is mandatory to examine all the records carefully, paying particular attention to the records of those providers who treated the claimant immediately after the accident. These are often the most accurate rendition of the incident and treatment that can be found. Records prior to the accident are even more critical, as they may be the only source of information regarding preexisting conditions. When there are no medical records from before and immediately after an accident, one cannot definitely establish that a causal relationship between current complaints and the accident exists--only that the claimant’s history supports the causal relationship. If the examiner believes that additional information, records, or tests are needed to support conclusions regarding relatedness, then it is necessary to state this and to describe exactly what information or testing is required.

               In conclusion, the examiner can only provide an accurate determination of causality if he or she applies accurate determination of causality assessment, within an objective framework, in which the claimant’s statements have validity only to the extent that they are supported by the medical records. In those instances where the medical records in inadequate, the examiner can make preliminary conclusions regarding causality, especially if the elements of temporal relationship and biologic plausibility have been met, but should reserve final judgment until the entire relevant medical record is available for review.

Information about Lilburn, Georgia

Lilburn, Georgia

Introduction to Lilburn, Georgia

Lilburn, Georgia, in Gwinnett county, is 13 miles E of Sandy Springs, Georgia and 17 miles NE of Atlanta, Georgia. The city is conveniently located inside the Atlanta metropolitan area. There are an estimated 11,307 people in Lilburn.

Lilburn History

Prior to 1817, the area now known as Lilburn was inhabited by Native Americans. The Seaboard Airline Railway established the city in 1890. Originally, the area was known as McDaniel. The first church of the region was established in 1823. Lilburn was incorporated on July 27, 1910.

Lilburn and nearby Attractions

• Yellow River Game Ranch
• Stone Mountain Park
• Mountain Park Aquatic Center & Activity Building
• Southeastern Railway Museum
• Zoo Atlanta Playspace
• Georgia Aquarium

Things To Do In Lilburn

There are several parks, playgrounds and scenic trails in Lilburn. You can visit the Lilburn City Park and the Camp Creek Greenway Trail during your leisure hours. Family day trips can also be planned at the Yellow River Game Ranch. The Mockingbird Lake, Sturdivant Lake and Spences Lake offer facilities for fishing and boating. There are also ample shopping opportunities in Lilburn.

Lilburn Transportation

Dobbins Air Reserve Base Airport can be reached within a few minutes.

Lilburn Higher Education

Higher educational facilities are provided by the Gwinnett College of Business, Devry Institute of Technology, Garmon Beauty College and Emory University.

Stone Mountain

Stone Mountain Stone Mountain, located in DeKalb County about ten miles northeast of downtown Atlanta, is the largest  exposed mass of granite in the world. A town at the base of the mountain bears the same name. Before 1800, Native Americans used the mountain as a meeting and ceremonial place. Stone Mountain emerged as a major tourist resort in the 1850s, attracting residents of nearby Atlanta and other cities. The carving of a Confederate memorial on the side of the mountain attracted national and international attention during the twentieth century. Today, Stone Mountain is a tourist attraction that draws approximately 4 million visitors a year.

Become a Historical Educator Member at Stone Mountain Park!

Become a Historical Educator Member at Stone Mountain Park!

We are excited to introduce to you our Historical Educator program. The initiative of this program is to
increase educational opportunities for teachers and students at Stone Mountain Park. Our program is built
on the belief that Historical Educators are dedicated to enriching their student’s curriculum with
educational resources and events outside of the classroom. This will be achieved through our exclusive
membership program.

How Do I become a member?
It’s easy! Historical Educator membership cards will be issued to certified public and private school
teachers that book educational field trips at Stone Mountain Park. This does not include teachers that book
science and geology programs.
What are the benefits of being a Historical Educator member?
As a member of the Historical Educator group, the member may visit any of the educational venues listed
below as often as they like during the calendar year. They will also receive complimentary parking.
Members may also bring one teaching colleague along as their guest. The member and their guest must
present a valid ID and the membership card at each venue.
Benefits of membership

 Complimentary parking with member card and ID
 Complimentary admittance to audit any already booked educational field trip program (subject to
space availability and will be arranged through the sales department)
 Complimentary entry to:
o Antebellum Plantation and Farmyard
o Discovering Stone Mountain Museum
o Indian Festival and Pow Wow in the fall

Do you want to know more about a program before you come?
As a member you may also arrange to audit any education program that is booked by another school. To
arrange this you may call 770-498-5636. This is subject to space availability and occasional cancellation.
Guidelines of membership
 Valid for the calendar year printed on membership card
 Member may bring one colleague as a guest each time they visit. Colleague must show a valid
educator ID to gain admittance to each venue.
 Membership is non-transferable.
 No other discounts or upgrades available with this membership card.
 Membership card and valid educator ID must be presented for main gate entry and to attractions
listed above.