<img style="float: right;" src="https://opedge.com/Content/OldArticles/images/2005-12_07/so.jpg" hspace="4" vspace="4" /> <b><i>Not every pedorthist faces a first-time workers-compensation case like this one!</i></b> When he first received his dramatic introduction to workers-comp injuries, Wayne Decker, CPed, and his wife Nancy were operating a custom bootmaking and pedorthic facility in Durango, Colorado. The Deckers now own and operate American Footcare and the Pedorthic Shoe Institute, a continuing education provider, in Henryetta, Oklahoma. A bush pilot was returning to pick up some fishing clients he had flown to a nearby lake earlier that week. However, his clients weren't at the lake, so he walked from his plane inland a bit to see if he could find them. He inadvertently came between a female grizzly and her two cubs. He raced for a tree and started climbing, since he had heard grizzlies couldn't climb trees. Wrong! As she started up the tree after him, he tried kicking her head to get her to leave, but then he accidentally stuck his foot right in her mouth, and she chomped down. The angry grizzly tried to pull him out of the tree and pulled part of the lateral side of his foot off. He then began to kick with the other foot, and she bit him on the lower calf. She then turned loose of the tree, thinking she would pull him down, but his muscle gave way instead. The grizzly stayed at the bottom of the tree for a couple of hours before she finally left, and the hapless pilot could climb down. By the time he arrived back at his plane, the fishermen were there, but neither one could fly, so he had to fly the plane out. At the hospital, doctors were able to reattach the calf muscle, but it did not have much function, as a result he had foot drop on his left side and the lateral side of his right foot was missing. The challenge for Decker then became providing the correct footwear and orthotic support to enable the pilot to continue working--including being able to hike when necessary as well as fly his plane. Decker built a high-top boot with enough room to accommodate an AFO for the left foot, with the boot for the right foot being constructed with ample filler and lateral support. When the bear bit down on the lateral side of his foot, she also pulled a peroneal muscle loose, so his foot really wanted to invert, Decker recalled. "We had to build a boot that would compensate for the loss of function of the peroneal muscle," he said. After describing his "hairy" (ouch!) introduction to workers comp in a session during last year's Pedorthic Footwear Association (PFA) Symposium & Exposition, Decker gave some helpful advice for pedorthists providing care in workers compensation cases. Decker also discussed the pedorthic approach to workers comp cases with <i>The O&P EDGE</i>. <h4>Evaluation and Treatment</h4> The first step is to evaluate the case--what has already been done, i.e., surgery, physical therapy, etc.--and what needs to be done to get the patient on his feet and back to work. "We see what the doctor has prescribed, and we determine if we are capable of doing it, or if we feel that there are other treatment options that the doctor may be unaware of which might help the patient a lot more," Decker explained. The next critical step is looking at what reimbursement will cover. "We determine what we can do, based on the amount that is covered; sometimes, we can get the amount increased, based on the doctor's prescription." Then, the pedorthist talks with the patient and asks questions such as, "Do you need to go back to work? How soon? Will you be going back to the same type of work, or will you be reassigned to a less physically demanding job?" Other questions revolve around recreational activities: "What kind of outside activities do you want to be able to do?" For instance, was the patient someone who used to go hiking, camping, or was involved in sports? Putting all these factors together helps determine what treatment and outcome the pedorthist will try to accomplish. Decker noted that sometimes physicians, as well as patients, may be unrealistic as to what is possible as far as restoring function through pedorthic treatment. However, on the positive side, Decker points out that with the teamwork of a pedorthist, an orthotist, and a physical or occupational therapist, there is much that can be done to restore the patient to optimal possible function. Decker stressed the importance of a pedorthist having a strong knowledge of foot and leg anatomy and biomechanics. "For instance, if certain damaged muscles are not able to function fully, we need to know what to do mechanically with our orthotic or our shoe. Being knowledgeable about those muscle groups and functions is critical to the outcome. We need to know what we have to do to make the foot function correctly." Amputations caused by work-related injuries also can involve the pedorthist. For instance, with a talar amputation, the foot will still continue to plantarflex due to the unopposed gastroc-soleus muscle group. "So we need to do something, such as using a brace and rocker sole, to help lift that toe up so that the foot does not snag on the ground as the patient walks," Decker said. Pedorthists also are concerned with a sound contralateral limb, since the patient tends to put more weight on it, and therefore, that leg too can become damaged over time. Decker recalls an oil well driller whose right leg was pulled off by a cable that had become looped around it. Coworkers grabbed the leg, and at the hospital, the leg was successfully reattached. However, the reattached leg was now shorter, and the man began to put more weight on the uninjured side. "So we had to build an orthosis to help reduce the stress on that side, and we also put a lift on the right side to balance that leg out a bit more," Decker recalled. <h4>Challenging Cases</h4> Crushing injuries are the most frequent cases he has seen, Decker said. Machinery runs over a worker's foot or it becomes caught in between a piece of equipment and a hard surface. However, Decker also has had some unusual and challenging cases besides the pilot who suffered the bear attack. The oil well driller also was a professional bull rider on weekends. After his injury, he no longer could ride bulls, but he became a judge at bull-riding events. He needed a pair of boots that would allow an AFO inside and which would enable him to move quickly out of the way if a bull came at him. Plus, the boots had to look like cowboy boots. Decker met that challenge. Another case involved a construction worker who helped build bridges. To do certain work on a bridge, the man had to work from a boat. While out on a job he fell out and the boat's propeller hit him in the calf muscle and severed the Achilles tendon. Although a surgeon was able to reattach the tendon, the scar tissue severely damaged his ability to plantarflex, "so that was another one where we worked with an orthotist, who built an AFO," Decker said. "We then built a work boot around the AFO and got him back to work." As these cases prove, jobs can be hazardous--in any given year, there are about 120,000 job-related foot injuries, about one-third of them toe injuries, according to the National Safety Council. However, pedorthists can play a key role in getting people back to work--and back to their lives.
