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Guideline Summary
Guideline Title
Knee & leg (acute & chronic).
Bibliographic Source(s)
Work Loss Data Institute. Knee & leg (acute & chronic). Encinitas (CA): Work Loss Data Institute; 2011. Various p.
Guideline Status

Note: This guideline had been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

FDA Warning/Regulatory Alert

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

  • August 1, 2013 – Acetaminophen External Web Site Policy: The U.S. Food and Drug Administration (FDA) notified healthcare professionals and patients that acetaminophen has been associated with a risk of rare but serious skin reactions. Acetaminophen is a common active ingredient to treat pain and reduce fever; it is included in many prescription and over-the-counter (OTC) products. These skin reactions, known as Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP), can be fatal. These reactions can occur with first-time use of acetaminophen or at any time while it is being taken. Other drugs used to treat fever and pain/body aches (e.g., non-steroidal anti-inflammatory drugs, or NSAIDS, such as ibuprofen and naproxen) also carry the risk of causing serious skin reactions, which is already described in the warnings section of their drug labels.

Scope

Disease/Condition(s)

Work-related knee and leg disorders

Guideline Category
Diagnosis
Evaluation
Management
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Orthopedic Surgery
Physical Medicine and Rehabilitation
Radiology
Rheumatology
Sports Medicine
Intended Users
Advanced Practice Nurses
Health Care Providers
Health Plans
Nurses
Physical Therapists
Physician Assistants
Physicians
Utilization Management
Guideline Objective(s)

To offer evidence-based step-by-step decision protocols for the assessment and treatment of workers' compensation conditions

Target Population

Workers with knee and leg ailments

Interventions and Practices Considered

The following interventions/procedures were considered and recommended as indicated in the original guideline document:

  1. Anterior cruciate ligament (ACL) reconstruction
  2. ACL diagnostic tests
  3. Acupuncture
  4. Aquatic therapy
  5. Autologous cartilage implantation (ACI)
  6. BioniCare® knee device
  7. Bone densitometry
  8. Bone-growth stimulators, electrical and ultrasound
  9. Bone scan (imaging)
  10. Causation determination
  11. Cetylated fatty acids (CFA) topical cream
  12. Chondroplasty
  13. Cold/heat packs
  14. Compression garments
  15. Computed tomography (CT)
  16. Continuous-flow cryotherapy/vasopneumatic cryotherapy
  17. Continuous passive motion (CPM) combined with physical therapy
  18. Corticosteroid injections (short-term use only)
  19. Diagnostic arthroscopy
  20. Durable medical equipment (DME)
  21. Exercise
  22. Flexionators (extensionators)
  23. Footwear, knee arthritis
  24. Functional improvement measures
  25. Fusion (knee)
  26. Game Ready™ accelerated recovery system
  27. Glucosamine/chondroitin (for knee arthritis)
  28. Home exercise kits
  29. Home health services
  30. Hospital length of stay (LOS)
  31. Hyaluronic acid injections
  32. Hyperbaric oxygen therapy (HBOT)
  33. Insoles/shoes
  34. Iontophoresis
  35. Knee brace
  36. Knee joint replacement/unicompartmental knee replacement
  37. KT 1000 arthrometer
  38. Lachman test
  39. Lateral retinacular release
  40. Lymphedema pumps/vasopneumatic devices (wound healing)
  41. Magnetic resonance imaging (MRI)
  42. Massage therapy
  43. Meniscal allograft transplantation
  44. Meniscectomy
  45. Magnetic resonance (MR) arthrography
  46. Neuromuscular electrical stimulation (NMES devices)
  47. Non-surgical intervention for patellofemoral pain syndrome (PFPS)
  48. Occupational and physical therapy
  49. Office visits
  50. Open reduction internal fixation (ORIF)
  51. Osteochondral autograft transplant system (OATS)
  52. Osteotomy
  53. Periosteal stimulation therapy (PST)/osteopuncture
  54. Pharmacotherapy
  55. Phonophoresis
  56. Physical medicine treatment
  57. Pivot shift test (MacIntosh test)
  58. Prostheses (artificial limb)
  59. Quadriceps tendon repair
  60. Radiography (x-rays)
  61. Restless legs syndrome (RLS)
  62. Return to work
  63. Rivaroxaban (Xarelto)
  64. SAMe (S-adenosylmethionine)
  65. Skilled nursing facility (SNF) care/skilled nursing facility LOS
  66. Static progressive stretch (SPS) therapy
  67. Tai Chi
  68. Taping
  69. Transcutaneous electrical nerve stimulation (TENS)
  70. Topical non-steroidal anti-inflammatory drugs (NSAIDs) (for knee arthritis)
  71. Transportation (to and from appointments)
  72. Ultrasound, diagnostic
  73. Venous thrombosis
  74. Walking aids (canes, crutches, braces, orthoses, and walkers)
  75. Wheelchair
  76. Work/activity restrictions
  77. Work conditioning/work hardening
  78. Wound dressings

The following interventions/procedures are under study and are not specifically recommended:

  1. ACL injury rehabilitation
  2. Custom fit total knee (CFTK) replacement
  3. Deep transverse friction massage (DTFM)
  4. Denervation surgery
  5. Education for knee replacement
  6. Extracorporeal shock wave therapy (ESWT)
  7. Interferential current therapy (IFC)
  8. Lateral pull test and patellar tilt test
  9. Manipulation under anesthesia (MUA)
  10. Microprocessor-controlled knee prostheses
  11. Platelet-rich plasma (PRP)
  12. Posterior cruciate ligament (PCL) repair
  13. Post-operative ambulatory infusion pumps (local anesthetic)
  14. Prolotherapy
  15. Pulsed magnetic field therapy (PMFT)
  16. Stem cell autologous transplantation
  17. Stretching and flexibility
  18. Therapeutic knee splint
  19. Unloader braces for the knee
  20. Vacuum-assisted closure wound healing

The following interventions were considered, but are not recommended:

  1. Anakinra (Kineret)
  2. Collagen meniscus implant (CMI)/Menaflex®
  3. Computer assisted surgery
  4. Computerized muscle testing
  5. Delayed treatment
  6. Diathermy
  7. Electromyographic biofeedback treatment
  8. Hardware implant removal (fracture fixation)
  9. Immobilization as primary treatment
  10. Interferential current therapy (IFC) for chronic pain or low back problems
  11. Joint active systems (JAS) splints
  12. Juvenile cartilage allograft tissue implant
  13. Kinesio tape (KT)
  14. Low level laser therapy (LLLT)
  15. Low level laser wound healing
  16. Magnet therapy
  17. Manipulation/chiropractic
  18. Mosaicplasty
  19. Power mobility devices (PMDs)
  20. Single photon emission computed tomography (SPECT)
  21. Traction, knee (skeletal traction treatment)
  22. Ultrasound, therapeutic
Major Outcomes Considered
  • Effectiveness of treatment in relieving pain and improving function
  • Sensitivity and specificity of diagnostic tests

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Work Loss Data Institute (WLDI) conducted a comprehensive medical literature review (now ongoing) with preference given to high quality systematic reviews, meta-analyses, and clinical trials published since 1993, plus existing nationally recognized treatment guidelines from the leading specialty societies. WLDI primarily searched MEDLINE and the Cochrane Library. In addition, WLDI also reviewed other relevant treatment guidelines, including those in the National Guideline Clearinghouse, as well as state guidelines and proprietary guidelines maintained in the WLDI guideline library. These guidelines were also used to suggest references or search terms that may otherwise have been missed. In addition, WLDI also searched other databases, including MD Consult, eMedicine, CINAHL, and conference proceedings in occupational health (i.e., American College of Occupational and Environmental Medicine [ACOEM]) and disability evaluation (i.e., American Academy of Disability Evaluating Physicians [AADEP], American Board of Independent Medical Examiners [ABIME]). Search terms and questions were diagnosis, treatment, symptom, sign, and/or body-part driven, generated based on new or previously indexed existing evidence, treatment parameters and experience.

In searching the medical literature, answers to the following questions were sought: (1) If the diagnostic criteria for a given condition have changed since 1993, what are the new diagnostic criteria? (2) What occupational exposures or activities are associated causally with the condition? (3) What are the most effective methods and approaches for the early identification and diagnosis of the condition? (4) What historical information, clinical examination findings or ancillary test results (such as laboratory or x-ray studies) are of value in determining whether a condition was caused by the patient's employment? (5) What are the most effective methods and approaches for treating the condition? (6) What are the specific indications, if any, for surgery as a means of treating the condition? (7) What are the relative benefits and harms of the various surgical and non-surgical interventions that may be used to treat the condition? (8) What is the relationship, if any, between a patient's age, gender, socioeconomic status and/or racial or ethnic grouping and specific treatment outcomes for the condition? (9) What instruments or techniques, if any, accurately assess functional limitations in an individual with the condition? (10) What is the natural history of the disorder? (11) Prior to treatment, what are the typical functional limitations for an individual with the condition? (12) Following treatment, what are the typical functional limitations for an individual with the condition? (13) Following treatment, what are the most cost-effective methods for preventing the recurrence of signs or symptoms of the condition, and how does this vary depending upon patient-specific matters such as underlying health problems?

Criteria for Selecting the Evidence

Preference was given to evidence that met the following criteria: (1) The article was written in the English language, and the article had any of the following attributes: (2) It was a systematic review of the relevant medical literature, or (3) The article reported a controlled trial – randomized or controlled, or (4) The article reports a cohort study, whether prospective or retrospective, or (5) The article reports a case control series involving at least 25 subjects, in which the assessment of outcome was determined by a person or entity independent from the persons or institution that performed the intervention the outcome of which is being assessed.

More information about the selection of evidence is available in the "Methodology Outline" and "Appendix A. ODG Treatment in Workers' Comp. Methodology description using the AGREE instrument" (see "Availability of Companion Documents" field).

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Ranking by Type of Evidence

  1. Systematic Review/Meta-Analysis
  2. Controlled Trial - Randomized (RCT) or Controlled
  3. Cohort Study - Prospective or Retrospective
  4. Case Control Series
  5. Unstructured Review
  6. Nationally Recognized Treatment Guideline (from www.guideline.gov External Web Site Policy)
  7. State Treatment Guideline
  8. Other Treatment Guideline
  9. Textbook
  10. Conference Proceedings/Presentation Slides

Ranking by Quality within Type of Evidence

  1. High Quality
  2. Medium Quality
  3. Low Quality
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

The Work Loss Data Institute (WLDI) reviewed each article that was relevant to answering the question at issue, with priority given to those that met the following criteria: (1) The article was written in the English language, and the article had any of the following attributes: (2) It was a systematic review of the relevant medical literature, or (3) The article reported a controlled trial – randomized or controlled, or (4) The article reported a cohort study, whether prospective or retrospective, or (5) The article reported a case control series involving at least 25 subjects, in which the assessment of outcome was determined by a person or entity independent from the persons or institution that performed the intervention the outcome of which is being assessed.

Especially when articles on a specific topic that met the above criteria were limited in number and quality, WLDI also reviewed other articles that did not meet the above criteria, but all evidence was ranked alphanumerically (see the "Rating Scheme for the Strength of the Evidence" field) so that the quality of evidence could be clearly determined when making decisions about what to recommend in the Guidelines. Articles with a Ranking by Type of Evidence of Case Reports and Case Series were not used in the evidence base for the Guidelines. These articles were not included because of their low quality (i.e., they tend to be anecdotal descriptions of what happened with no attempt to control for variables that might affect outcome). Not all the evidence provided by WLDI was eventually listed in the bibliography of the published Guidelines. Only the higher quality references were listed. The criteria for inclusion was a final ranking of 1a to 4b (the original inclusion criteria suggested the methodology subgroup), or if the Ranking by Type of Evidence was 5 to 10, the quality ranking should be an "a."

Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

The guideline developers reviewed published cost analyses.

Method of Guideline Validation
External Peer Review
Description of Method of Guideline Validation

Prior to publication, select organizations and individuals making up a cross-section of medical specialties and typical end-users externally reviewed the guideline.

Recommendations

Major Recommendations

Note: This guideline had been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

Note from the Work Loss Data Institute (WLDI) and the National Guideline Clearinghouse (NGC): The following recommendations were current as of April 28, 2011. However, because the Work Loss Data Institute updates their guidelines frequently, users may wish to consult the WLDI Web site External Web Site Policy for the most current version available.

Initial Diagnosis

Knee ailments are among the ten most common causes of reported work-related complaints and workers' compensation claims. Initially, the practitioner should make sure that there are no indications of a potentially serious disease or condition (red flags), the presence of which would require that the patient be referred immediately to a specialist. In the absence of such red flags, the occupational provider can safely manage the healing process.

Initial Evaluation

First visit: with Primary Care Physician MD/DO (100%)

  • Check for serious underlying conditions often indicated by deformity or bone crepitation (fractures); displaced patella, tibia, or fibula (dislocation); severe pain with motion; infection; additional pain in the back or hip; excessive swelling; nontender mass (possibly indicating tumor); or neurovascular symptoms such as pale, cold skin; painless swelling; and/or paralysis.
  • Determine the incident or incidents that caused the complaint, especially torsion, fixed foot "pop," external lateral force, or forward force with abrupt halt in gait.
  • Determine whether the problem is acute, subacute, chronic, or of insidious onset.
  • Determine the severity and specific anatomic location of the pain.
  • Describe location and severity of pain.
  • Assess the ability of the patient to lift and carry weight, from no to full lifting ability.
  • Assess the ability to climb stairs and hills and walk on uneven ground.
  • Determine any present medication.
  • Determine any previous medical history, history of systemic disease, or history of previous knee injury, previous knee surgery, discomfort, or related disability.
  • Investigate non-industrial reasons that commonly exacerbate knee complaints (i.e., recreational sports or other exercise that aggravates the knee, degenerative disorders, and past acute injury)
  • Compare clinical exam findings of injured knee to opposite knee.

Presumptive Diagnosis

  • Observe the patient's walk and stance for abnormalities, including swelling, deformity, discoloration, inability to extend, and difficulty walking.
  • Examine the knee in an extended position for tenderness and range of motion.
  • Check for ligament stability while applying pressure with the joint slightly flexed.
  • Pull the tibia forward to examine the knee at 30 degrees (Lachman test). Problems with both flexation and extension at once could indicate the need for surgery.
  • Aspiration can be used on initial atraumatic effusions but only if there is no sign of cellulitis/infection of the skin.
  • Anterior knee pain, popping and clicking, and possible cartilage loss (shown through magnetic resonance imaging [MRI]) are indicators of patellofemoral syndrome.
  • Other anterior knee pains, along with tenderness over the patellar tendon, could be signs of patellar tendonitis.
  • Swelling over the tibial tubercle could indicate Osgood-Schlatter disease, a congenital condition (common in adolescents – not work related).
  • Prepatellar bursitis and contusion/periostitis could be caused by direct force, prepatellar bursitis by repetitive friction force.
  • Unexplained knee pain, semi-locking, catching, and swelling could be patellofemoral instability, which is often mistaken for a ligament injury. Patellofemoral instability is successfully treated with physical therapy.
  • Neurologic condition should be assessed, especially in regard to evidence of lumbar disk disease with possible radiation to the knee.
  • Immediate referral is recommended for patients with neurologic symptoms, infections, tumor, or deformity.

Initial Therapy

The first step is to reduce pain and make the patient feel comfortable, usually with nonprescription analgesics or prescribed pharmaceuticals if necessary. At-home exercises, such as bicycling and straight leg lifting, or other retraining and weight-bearing activities may aid in rehabilitation, although a physical therapist may be necessary depending on patient motivation and degree of pain. Exercise and movement have been shown to be more beneficial than total rest, but care must be taken not to overload the knee during weight bearing exercises.

Imaging

If a fracture is considered, patients should have radiographs if the Ottawa criteria are met. Among the 5 decision rules for deciding when to use plain films in knee fractures, the Ottawa knee rules (injury due to trauma and age >55 years, tenderness at the head of the fibula or the patella, inability to bear weight for 4 steps, or inability to flex the knee to 90 degrees) have the strongest supporting evidence. Diagnostic performance of magnetic resonance (MR) imaging is recommended for the menisci and cruciate ligaments of the knee.

Surgery

Immediate emergency surgery is usually unnecessary with knee injuries unless there is a need to drain acute effusions. Otherwise, most knee problems are greatly improved with physical methods alone. Only when exercise programs are unable to increase strength and range of motion in the knee after more than a month should surgery be considered, and even then it may not be necessary. Surgery may be considered in the following cases:

Anterior Cruciate Ligament (ACL) Tears: The decision on whether or not to surgically repair an ACL tear should take into account the patient's work and life needs. For those whose life does not include active use or load of the knee, surgery may be unnecessary. The rehabilitation process following surgery involves six months of very intense therapy, so non-surgical recovery should be allowed to occur as much as possible before any surgery takes place. Confirmation of a complete tear in the ligament through MRI findings, clear signs of instability confirmed through the Lachman and pivot test, and a history of frequent falls or giving way are consistent with this condition. See ODG Indications for Surgery -- Anterior cruciate ligament (ACL) repair in the original guideline document.

Official Disability Guidelines (ODG) Return-to-Work Pathways

Severe (tear), Grade III1, ACL repair, sedentary/modified work: 35 days
Severe (tear), ACL repair, manual/standing work: 180 days

(See ODG Capabilities & Activity Modifications for Restricted Work under "Work" in the Procedure Summary in the original guideline document)

1Definition of Sprain/Strain Severity Grade: In general, a Grade I or mild sprain/strain is caused by overstretching or slight tearing of the ligament/muscle/tendon with no instability, and a person with a mild sprain usually experiences minimal pain, swelling, and little or no loss of functional ability. Although the injured muscle is tender and painful, it has normal strength. A Grade II sprain/strain is caused by incomplete tearing of the ligament/muscle/tendon and is characterized by bruising, moderate pain, and swelling, and a Grade III sprain/strain means complete tear or rupture of a ligament/muscle/tendon. A sprain is a stretch and/or tear of a ligament (a band of fibrous tissue that connects two or more bones at a joint). A strain is an injury to either a muscle or a tendon (fibrous cords of tissue that connect muscle to bone).

Collateral Ligament Tears: Surgery is usually unnecessary; healing often occurs with rehabilitative exercises alone.

Meniscus Tears: Patients with meniscus tears that are not severely limiting or progressive may not need surgical attention. In patients younger than 35, arthroscopic meniscal repair can preserve meniscal function, although the recovery time is longer compared to partial meniscectomy. Arthroscopy and meniscus surgery may not be as beneficial for older patients who are exhibiting signs of degenerative changes, possibly indicating osteoarthritis.

ODG Return-To-Work Pathways

Without surgery, clerical/modified work: 0 to 2 days
Without surgery, manual/standing work: 21 days
With arthroscopy, clerical/modified work: 14 days
With arthroscopy, manual/standing work: 42 days
With arthrotomy, clerical/modified work: 28 days
With arthrotomy, manual/standing work: 56 days
With arthrotomy, heavy manual/standing work: 84 days

Osteochondral Defects: Studies are still being done to test the effectiveness of osteochondral autograft transplant system (OATS) procedures for osteochondral defects. Patients under 40 years old with active lifestyles may benefit from OATS, and the procedure may delay the development of osteoarthritis.

Patellofemoral Syndrome (PFS): While commonly treated with arthroscopic patellar shaving, this procedure is not proven in terms of long-term improvement. In cases of severe patellar degeneration, surgery is usually not helpful. For patients with rheumatoid conditions, patellectomy and patellar replacements are sometimes performed on active patients. Other possible surgeries for PFS are lateral arthroscopic release and surgical realignment of the extensor mechanism.

ODG Return-To-Work Pathways

Arthroscopy, clerical/modified work: 7 to 10 days
Arthroscopy, manual work: 28 days
Arthroscopy, debridement of cartilage, clerical/modified work: 7 to 14 days
Arthroscopy, debridement of cartilage, manual work: 30 days
Arthrotomy, clerical/modified work: 21 days
Arthrotomy, manual work: 49 days

Arthritis: Therapeutic exercises are beneficial for knee osteoarthritis. Acetaminophen is an effective agent for relief of knee pain. Although safer, it is less effective than nonsteroidal anti-inflammatory drugs (NSAIDs). For safety reasons acetaminophen should be the first line treatment, with NSAIDs reserved for those who do not respond. Glucosamine may provide effective symptomatic relief for patients with osteoarthritis of the knee. In addition, glucosamine has shown promising results in modifying the progression of arthritis over a 3-year period. Glucosamine has a tolerability profile similar to that of placebo and is better tolerated than ibuprofen or piroxicam. Intra-articular (IA) injection of hyaluronic acid (e.g., Synvisc) can decrease symptoms of osteoarthritis of the knee. The short-term benefit of IA corticosteroids in treatment of knee osteoarthritis is well established, and few side effects have been reported. Longer-term benefits have not been confirmed. Total knee arthroplasties are well accepted as reliable and suitable surgical procedures to return patients to function.

ODG Return-To-Work Pathways

Medical treatment: 0 days
Visco injection, knee: 7 days
Partial arthroplasty, knee: 28 days
Arthroplasty, knee, clerical/modified work: 42 days
Arthroplasty, manual work: 84 days
Obesity comorbidity (body mass index [BMI] ≥30), multiply by: 1.31

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

During the comprehensive medical literature review, preference was given to high quality systematic reviews, meta-analyses, and clinical trials over the past ten years, plus existing nationally recognized treatment guidelines from the leading specialty societies.

The heart of each Work Loss Data Institute guideline is the Procedure Summary (see the original guideline document), which provides a concise synopsis of effectiveness, if any, of each treatment method based on existing medical evidence. Each summary and subsequent recommendation is hyper-linked into the studies on which they are based, in abstract form, which have been ranked, highlighted and indexed.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

These guidelines unite evidence-based protocols for medical treatment with normative expectations for disability duration. They also bridge the interests of the many professional groups involved in diagnosing and treating work-related knee ailments.

Potential Harms
  • There is no evidence to suggest that reconstruction of the anterior cruciate ligament (ACL) prevents or reduces the rate of early-onset osteoarthritis (OA). On the contrary, the prevalence of OA may be even higher in patients with reconstructed ACL than in those with non-reconstructed ACL.
  • Total and partial meniscectomies are associated with altered load bearing across the joint, frequently resulting in degenerative osteoarthritis.
  • The safety of simultaneous bilateral total knee replacement remains controversial. Compared with staged bilateral or unilateral total knee replacement, simultaneous bilateral total knee replacement carries a higher risk of serious cardiac complications, pulmonary complications, and mortality.
  • As with all injections, care must be given to watch for any possible adverse events, and particularly with the use of Hylan over hyaluronic acid.
  • Oral nonsteroidal anti-inflammatory drugs (NSAIDs) appear to produce more minor adverse effects than topical NSAIDs.
  • A strapped insole has more adverse effects than a lateral wedge insole.

Contraindications

Contraindications
  • Contraindications to use of iontophoresis include allergy or sensitivity to the substance being applied, open wounds, or impaired sensation. Iontophoresis also should not be used in the immediate vicinity of metallic implants, wires, or staples.
  • Ultrasound heating should not be used near malignant tumors, nerve tissue in a patient who has recently had a laminectomy, joint replacements, permanent pacemakers, thrombophlebitis, eyes, reproductive organs, areas of acute inflammation, epiphyseal plates, or over breast implants.

Qualifying Statements

Qualifying Statements

The Treatment Planning section is not designed to be a rule, and therefore should not be used as a basis for Utilization Review. The Treatment Planning section outlines the most common pathways to recovery, but there is no single approach that is right for every patient and these protocols do not mention every treatment that may be recommended. See the Procedure Summaries (in the original guideline document) for complete lists of the various options that may be available, along with links to the medical evidence. The Procedure Summaries are the most important section of Official Disability Guidelines (ODG) Treatment, and that section, not the Treatment Planning section, should be used as a basis for Utilization Review.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Patient Resources
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Work Loss Data Institute. Knee & leg (acute & chronic). Encinitas (CA): Work Loss Data Institute; 2011. Various p.
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2003 (revised 2011 Apr 28)
Guideline Developer(s)
Work Loss Data Institute - For Profit Organization
Source(s) of Funding

Not stated

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Editor-in-Chief, Philip L. Denniston, Jr. and Senior Medical Editor, Charles W. Kennedy, Jr., MD, together pilot the group of approximately 80 members. See the ODG Treatment in Workers Comp Editorial Advisory Board External Web Site Policy.

Financial Disclosures/Conflicts of Interest

There are no conflicts of interest among the guideline development members.

Guideline Status

Note: This guideline had been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Guideline Availability

Electronic copies of the updated guideline: Available to subscribers from the Work Loss Data Institute Web site External Web Site Policy.

Print copies: Available from the Work Loss Data Institute, 169 Saxony Road, Suite 210, Encinitas, CA 92024; Phone: 800-488-5548, 760-753-9992, Fax: 760-753-9995; www.worklossdata.com External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Methodology outline is available from the Work Loss Data Institute (WLDI) Web site External Web Site Policy.
  • Appendix A. Official Disability Guidelines (ODG) Treatment in Workers' Comp. Methodology description using the AGREE instrument. Available from the WLDI Web site External Web Site Policy.
  • ODG for eReader. Treatment and disability duration guidelines are available for purchase from the WLDI Web site External Web Site Policy.
Patient Resources

The following is available:

  • Appendix C. Official Disability Guidelines (ODG) Treatment in Workers' Comp. Patient information resources. Electronic copies: Available to subscribers from the Work Loss Data Institute Web site External Web Site Policy.

Print copies: Available from the Work Loss Data Institute, 169 Saxony Road, Suite 210, Encinitas, CA 92024; Phone: 800-488-5548, 760-753-9992, Fax: 760-753-9995; www.worklossdata.com External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This summary was completed by ECRI on February 2, 2004. The information was verified by the guideline developer on February 13, 2004. This NGC summary was updated by ECRI on March 28, 2005, January 12, 2006, November 10, 2006, March 30, 2007, August 28, 2007, January 22, 2009, and June 7, 2011. This summary was updated by ECRI Institute on October 28, 2013 following the U.S. Food and Drug Administration advisory on Acetaminophen.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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