RECOMMENDED CHANGES TO PROPOSED RULE 17(April 28 - 2009) Exhibit 6 -LOWER EXTREMITY INJURY MEDICAL TREATMENT GUIDELINES
Changes throughout Exhibit #6
•	Spelling/capitalization, punctuation, formatting, numbering/lettering, and grammatical changes
•	Pagination (including Table of Contents)
•	Sentence order changes
	
SECTION	PAGE NUMBER	DESCRIPTION OF CHANGE	
Table of contents	None	Adjust titles to coincide with titles in text	
SECTION C:  INITIAL DIAGNOSTIC PROCEDURES	
C. 1.a.  ix. History of Present Injury	5-6	INSERT: Lower extremity injuries are frequently not isolated, but are accompanied by other injuries.  In the setting of a traumatic brain injury (TBI), long bone fracture management must consider the effect of TBI on bone metabolism and may require more aggressive treatment.  Refer to the Traumatic Brain Injury Medical Treatment Guidelines, Section G. 3. f, Musculoskeletal Complications. 	
C. 2. c. ix.  Foot and ankle exam	8	INSERT:  'Morton's' so that the phrase reads:  '….and posterior tibial tendon; Morton's neuroma; and the piano key test…..'	
C. 4.  Other Procedures	10	INSERT:  'centigrade' so that the phrase reads:  '37.5 degrees centigrade…'	
SECTION E:  SPECIFIC LOWER EXTREMITY INJURY DIAGNOSIS, TESTING, AND TREATMENT:  FOOT AND ANKLE	
E. 1. a. v.  Achilles Tendonopathy or Injury and Rupture-Non-operative Treatment Procedures	17	INSERT:  'and Medical Management.'  so that the phrase reads, '…..Section F. 7, Medications and Medical Management.'
***This change is due to a retitled subsection, therefore this insertion occurs throughout the guidelines where appropriate.	
E. 1. b. ii.  Aggravated Osteoarthritis-Occupational Relationship	18	INSERT:  'the joint' so that the phrase reads:  '….may predispose the joint to osteoarthritis.'	
E. 1. b. iv.  Aggravated Osteoarthritis-Surgical Indications/Considerations	20	STRIKE:  'physical' so that the phrase reads:  '…after non-surgical interventions including weight control, physical therapy…'	
E. 1. d. v. K)  Ankle Sprain/Fracture- Non-operative Treatment Procedures	25	INSERT:  'therapy' so that the phrase reads:  'Hyperbaric oxygen therapy is not recommended.'	
SECTION E:  SPECIFIC LOWER EXTREMITY INJURY DIAGNOSIS, TESTING, AND TREATMENT:  KNEE	
E. 2.  a.  Aggravated Osteoarthritis- Non-operative Treatment Procedures	49	STRIKE:  'physical' so that the phrase reads, '…..active intervention when land-based 'physical' therapy is not well-tolerated.	
E. 2. d. iv. A) Chondral and Osteochondral Defects-Surgical Indications/ Considerations 	56	STRIKE:  'therapy' and INSERT: 'surgical treatment' so that the phrase reads: 'Normally the first line of therapy surgical treatment.'

STRIKE:  'physical' so that the phrase reads:  not recovered functionally after active participation in 'physical' therapy.  	
SECTION E:  SPECIFIC LOWER EXTREMITY INJURY DIAGNOSIS, TESTING, AND TREATMENT:  HIP/LEG	
E. 3. a.  Aggravated Osteoarthritis-Occupational Relationship	75	INSERT:  'the joint' so that the phrase reads:  '….may predispose the joint to osteoarthritis.'

INSERT:  'prior' so that the phrase reads, 'The prior injury should have been at least….'

STRIKE:  'physical' so that the phrase reads, '…..active intervention when land-based 'physical' therapy is not well-tolerated.	
SECTION F:  THERAPEUTIC PROCEDURES-NON-OPERATIVE	
Introduction	95	INSERT: Treating providers, as well as employers and insurers are highly encouraged to reference the General Guidelines Principles (Section B) prior to initiation of any therapeutic procedure.	
SECTION F:  THERAPEUTIC PROCEDURES-NON-OPERATIVE	
F. 5.d. Viscosupplementation/Intracapsular Acid Salts	100-101	STRIKE: Viscosupplementation is not recommended for hip or ankle osteoarthritis due to the small effect in knee conditions and the lack of evidence supporting use for hip or ankle osteoarthritis.

INSERT: One injection of 6 ml of hylan G-F 20 may be effective and is an option for knee injections.
 
INSERT: Viscosupplementation is not recommended for ankle osteoarthritis due to the small effect size documented in knee conditions and the lack of evidence supporting its use in the ankle.  Viscosupplementation is not recommended for hip arthritis given the probable superiority of corticosteroid injections. In rare cases a patient with significant hip osteoarthritis who does not qualify for surgical intervention may try viscosupplementation. It should be done with ultrasound or fluoroscopic guidance and will not necessarily require a series of three injections. The patient may choose to have repeat injections when the first injection was successful. 

INSERT: ‘or one injection as discussed above’ under Time to Produce Effect.

INSERT: ‘One injection or’ under frequency.
	
G. 1. g. i. Ankle and Subtalar Fusion-Post-operative treatment	123	STRIKE:  'physical'  so that the phrase reads, 'In all cases, communication between the physician and physical therapist is important….'

***this change also for: 2. knee fusion, 3. ankle arthroplasty, 4. knee arthroplasty, 5. hip arthroplasty, 8. osteotomy	
G. 4. g. iv.  Knee Arthroplasty- Surgical Considerations	129	STRIKE:  'physical' and INSERT:  'active' so that the phrase reads, '…..accompanied by focused, active physical therapy.'
	
G. 5. e. Hip Arthroplasty- Surgical Considerations	130	INSERT:  'Prior to surgery, patients may be assessed for any associated mental health or low back pain issues that may affect rehabilitation.
	
G. 7. e. Manipulation Under Anesthesia-Surgical Indications/Considerations	133	STRIKE: ' physical' so that the phrase reads, 'Consider if routine therapeutic modalities, including ' physical' therapy and/or …..'