Surgery, Recovery
and Return to Work
Expectations
GENEX Services, Inc.
Karyn Versteeg, RN, BS
OSIA Winter Conference, 2013
Carpal Tunnel Release
• Generally, an incision is made over the area of tendon
attachment, the tendon tissue is cut away from the bone,
allowing the tendon to relax or pull back towards the muscle
belly.
• It may not be necessary to release the entire tendon to
decrease tension on the muscle tendon unit. If the tendon is to
be reattached (transposed) to another location, the incision is
larger and the procedure more complicated.
• De Quervain's release is a minor surgical procedure
accomplished through a small incision exposing the tendon
sheath (retinaculum) along the thumb (radial) side of the wrist.
The sheath is cut (released) around the two tendons at the
base of the thumb and portions of the sheath may be excised.
• The release is done under regional or local anesthesia in an
outpatient setting.
Recovery
• Following the surgical protocol and healing, grip
and pinch exercises are introduced between 2
weeks and 4 weeks postoperatively.
• When the tendons can tolerate, more strenuous
activities
are
introduced
after
6
weeks
postoperatively to restore full hand function.
Treatment usually is completed within 12 weeks.
• As therapy progresses, exercises should be
reflective of the work environment, which must be
reassessed in preparation for the individual's safe
return to work. An ergonomic assessment may be
indicated.
Return to work
• Job Classification
RTW Min/Max
• Sedentary Work
1 days - 3 weeks
• Light Work
1 days - 3 weeks
• Medium Work
1 days - 3 weeks
• Heavy Work/
Very Heavy Work
3 weeks - 6 weeks
Barriers
•Cervical radiculopathy
•Cervical spondylosis at C5-C6
•Diabetes
•Fluid retention with tissue swelling
•High blood pressure
•Hypothyroidism
•Injury to the hand or wrist
•Obesity
•Renal failure
•Rheumatoid arthritis
Triangular Fibrocartilage Complex
Tears(TFCC)
• The central portion of the TFCC has no direct blood
supply, large central disc tears do not heal well and
may require arthroscopic surgery to trim or remove
torn cartilage while leaving the support ligaments in
place.
• Wrist arthroscopy may be performed under general
or regional anesthesia to smooth (debride) or
remove (excise) unstable fragments of cartilage.
Peripheral tears of the cartilage disc may be
repaired with stitches.
Recovery
• After surgery, the wrist is immobilized in a splint for 2
weeks, reassessed for healing, and then reimmobilized in a removable splint for an additional 4
weeks to allow range of motion exercises to begin.
• Strengthening exercises may be initiated once the
individual has regained 80% of normal wrist range of
motion.
• The individual may return to sports and lifting
activities at 5 to 6 weeks post injury as symptoms
allow.
Return to Work
• Job Classification
RTW Min/Max
• Sedentary Work
1 week - 2 weeks
• Light Work
2 weeks – 4 weeks
• Medium Work
3 weeks - 4 weeks
• Heavy Work
4 weeks- 8 weeks
• Very Heavy Work
6 weeks - 12 weeks
Barriers
•
•
•
•
•
•
•
Time delay from injury to procedure
Osteoarthritis
Rheumatoid arthritis
Diabetes
Vascular disease
Infection
Demand of job at injury
Rotator Cuff/Biceps Tendon Repair
• Several different surgical procedures are used in
repairing the rotator cuff.
• One procedure involves smoothing (debriding) the
ragged edges of the torn tendon and suturing the
tissue edges together.
• Often, the end of the tendon must be reattached
to the upper arm (humeral head) as well. If the gap
created by the tear is too large and/or the tissue
too stiff to be pulled together again, a graft may be
necessary to cover the humeral head.
• Alternatively, the remaining tendon can be sutured
into a bone trough made in the humeral head.
Recovery
• As the pain and inflammation ease, treatment aims
at improving strength and flexibility to the shoulder
without irritating the healing tendon(s).
• The strengthening exercises begin with scapular
muscles. These are important muscles for normal
shoulder function, and the exercises can usually be
performed without excessively stressing the healing
tendon(s).
• Gentle stretching exercises may be initiated,
avoiding stress on the healing tendon(s). As the
tendon heals, strengthening exercises are added,
as indicated.
• Sling is worn for 4-6 wks to keep shoulder stationary
Return to work
• Job Classification
RTW Min/Max
• Sedentary Work / Light Work
1 week - 3 weeks
• Medium Work
4 weeks - 8 weeks
• Heavy Work/Very Heavy Work 8 weeks - 12 weeks
* Disability may be permanent if work
requires arms overhead
Barriers
• Age of tissue (not necessarily the age of the
patient)
• Post-operative inactivity
• Smoking
• Dominant arm
Meniscus repair/Meniscectomy
• Tears along the inner curve of the meniscus where
the blood supply is poor, especially those that are
of the ragged, degenerative type, are most
commonly treated by removing the damaged part
of the meniscus (partial meniscectomy).
• Tears near the outer rim of the meniscus where the
blood supply is rich may be repaired with stitches
(meniscus repair).
• With either procedure, any avascular fragments of
cartilage are removed.
• The surgery concludes by removing the arthroscope
and tools and closing the small incisions with sutures.
Anatomy of the Knee
Recovery
• If a meniscal repair has been performed, extreme flexion and
rotation should be limited until the wound in the meniscus has
had time to heal (8 to 12 weeks).
• Knee range of motion exercises can help to restore full
mobility to the joint.
• Therapy should progress to strengthening exercises as
tolerated, and it should include flexibility exercises throughout
the period of strengthening.
• While strong muscles around the joint are critical, flexibility of
the same muscle groups must be considered.
• Although a meniscus can heal within approximately 12 weeks,
the joint may still need to be protected from heavy loading
until the meniscus has regained its full strength.
• If a meniscectomy were performed, the degree of knee
loading during work and leisure activities must be considered
and discussed with the physician prior to return to work.
Return to work (meniscus repair)
• Job Classification
RTW Min/Max
• Sedentary Work
2 weeks - 3 weeks
• Light Work
6 weeks - 8 weeks
• Medium Work
8 weeks - 12 weeks
• Heavy Work/
Very Heavy Work
12 weeks - 24 week
Return to work (meniscectomy)
• Job Classification
RTW Min/Max
• Sedentary Work
1 weeks - 2 weeks
• Light Work
2 weeks - 4 weeks
• Medium Work
2 weeks - 4 weeks
• Heavy Work/
Very Heavy Work
4 weeks- 6 weeks
Barriers
•
•
•
•
•
•
•
Obesity
Female
Osteoarthritis
Synovitis (inflammation in the interior joint)
Amount of tissue taken (meniscectomy)
Ligament injuries
May increase rate of degeneration with time
Anterior Cruciate Repair (ACL)
• The ligament is reconstructed by taking a piece of
tendon from a different part of the body or from a
donor and connecting it to the shinbone and
thighbone.
• Although there are different methods for ACL
reconstruction, they all involve the same basic
procedure.
• An incision is made in the individual's leg, and small
tunnels are drilled into the bone.
• Then the new or harvested ACL is brought through
the tunnels and secured with a staple-and-buckle
system.
ACL Anatomy
Recovery
• Rehabilitation, requiring months of intense exercise,
is recommended for successful recovery from a
surgical repair of the anterior cruciate ligament.
• Rehabilitation following anterior cruciate ligament
repair follows a structured process beginning
immediately after the surgical repair and ending
with the individual returning to work and other
activities.
• The entire process can take up to 9 months.
Return to work
• Job Classification
RTW Min/Max
• Sedentary Work
3 weeks - 6 weeks
• Light Work
4 weeks - 12 weeks
• Medium Work
12 weeks - 24 weeks
• Heavy Work/Very Heavy Work by report
Barriers
•
•
•
•
•
•
Females 2-8 times more likely for injury
Osteoarthritis in the joint
Arthrofibrosis (scar tissue build up)
Synovitis (inflammation of the inner joint cavity)
Obesity
Other knee injuries
Discectomy
• A discectomy is the surgical removal of herniated disc
material from the spinal canal.
• The discs between the spinal vertebrae consist of a gel-like
center enclosed in a fibrous covering.
• A herniated disc occurs when the covering is damaged
and the gel-like material is extruded.
• Discectomy is accomplished either by direct incision over
the affected vertebra and underlying disc (open
discectomy), through a small incision using a microscope
and special equipment (microdiscectomy), or by laser
(laser discectomy).
• The surgery includes removing fragments of the disc that
has been herniated to relieve pressure on the affected
nerve root.
• Discectomy can be performed to remove cervical discs
from the neck region, thoracic discs from the mid-back, or
lumbar discs from the lower back.
Recovery
• Usually around 4 to 6 weeks postoperatively,
patients may be progressed to a more aggressive
exercise program.
• Rehabilitation
should
emphasize
stretching,
strengthening, stabilization and aerobic exercises as
well as instruction of proper body mechanics.
Stretching, strengthening and stabilization exercises
should focus on the muscles around the trunk, hips,
and thighs.
• Improved general aerobic conditioning has been
shown to yield better postoperative outcome. Low
impact activities, such as walking and swimming,
may be beneficial after discectomy to improve
general fitness.
Return to Work
• Job Classification
RTW Min/Max
• Sedentary Work
4 weeks - 6 weeks
• Light Work
4 weeks - 6 weeks
• Medium Work
6 weeks - 10 weeks
• Heavy Work/Very Heavy Work by report
Barriers
•Alcohol Abuse
•Degenerative spine conditions (arthritis, ankylosing
spondylitis)
•Infection
•Inflammatory disease
•Malnutrition
•Nerve root damage
•Obesity
•Poor physical conditioning
•Tobacco abuse
Laminectomy/Laminotomy
• Laminectomies and Laminotomies are performed
under general anesthesia.
• The individual is positioned face down on a wellpadded laminectomy frame or spinal board. X-rays
may be taken to confirm the location.
• An incision is made in the middle of the back or
neck over the area of involvement. The muscles
beneath the skin are spread apart to expose the
laminae overlying the spinal cord and nerve roots.
Bone is removed using a bone cutter or air drill.
• As noted above, the amount of bone removed will
depend on the amount of exposure or
decompression necessary.
Recovery
• Outpatient physical therapy begins approximately 1
month after surgery.
• Modalities such as ice or heat may be used to reduce
pain and swelling and decrease muscle spasm.
Increasing range of motion is the second objective of
rehabilitation.
• This is especially important due to the prolonged time
that the individual wears a brace.
• Strengthening and conditioning exercises such as
walking or swimming to increase endurance and
strength as tolerated.
• Therapy also addresses correct posture, proper body
mechanics, and ergonomics. Individuals learn strategies
to sit and stand in positions of ease, to reach and lift in a
way that protects the back and neck, and to pace
activities.
Return to work
• Job Classification
RTW Min/Max
• Sedentary Work
4 weeks-6 weeks
• Light Work
4 weeks- 6 weeks
• Medium Work
6 weeks – 8 week
• Heavy Work/Very Heavy Work by report
Barriers
•Obesity
•Osteoarthritis
•Prior spinal or abdominal surgery
Spinal Fusion
• Spinal fusion is the surgical immobilization of two or
more adjacent bones of the spinal column
(vertebra).
• Multiple bones are fused or made to grow together
to become one solid bone.
• For all types of spinal fusion, the segment of the
spine is ultimately immobilized with a bone graft,
which serves as a scaffold for new bone growth to
create a bony union between two or more
adjacent vertebrae.
• For fusion to succeed, bone cells must develop into
mature cells that reproduce and grow throughout
the fusion matrix until new bone forms, fusing the
vertebrae together.
Recovery
• Approximately 4 to 6 weeks postoperatively, or
when recommended by the surgeon, isometric
training of the trunk muscles can be initiated.
General conditioning exercises of the upper and
lower extremities, and aerobic training are initiated
and progressed as indicated.
• Activities that promote trunk flexion should be
avoided until approved by the surgeon.
• Once trunk flexion is advised, then general trunk
flexibility, strengthening, and endurance exercises
can be taught and progressed as tolerated.
• An ergonomic assessment may be beneficial to
modify the workplace as needed and ensure the
work status of the individual.
Return to work
• Job Classifications
RTW Min/Max
• Sedentary Work
16 weeks - 20 weeks
• Light Work
22 weeks - 26 weeks
• Medium Work
26 weeks - 32 weeks
• Heavy/Very Heavy Work by report
Steroid Injections
• An epidural steroid injection is performed to help reduce
the inflammation and pain associated with nerve root
compression.
• Nerve roots can be compressed by a herniated disc,
spinal stenosis, and bone spurs. When the nerve is
compressed it becomes inflamed.
• This can lead to pain, numbness, tingling or weakness
along the course of the nerve. This is called
radiculopathy.
• The goal of the epidural steroid injection is to help lessen
the inflammation of the nerve root and will take up to 14
days for full effect.
• The epidural space is located above the outer layer
surrounding the spinal cord and nerve roots. An epidural
steroid injection goes into the epidural space, directly
over the compressed nerve root.
Recovery
• Follow-up appointment after the epidural steroid
injection is likely between two to six weeks after the
injection to determine how the patient has
responded to the injection and if they have any
continued symptoms from the nerve compression.
• If the patient continues to have symptoms or if they
return after a period of time they may consider
having the injection repeated.
• Most physicians recommend no more than 3-4
injections during a year, while ODG recommends
no more than 2 and then move on to a new
treatment.
Return to Work
• Job Classification
RTW Min/Max
• Sedentary Work
1day – 3 days
• Light Work
1day - 3 days
• Medium Work
1 day – 3 days
• Heavy Work/
Very Heavy Work
2 days - 5 days
Barriers
•Leg length difference greater than one inch
•Obesity
•Osteoarthritis
•Osteoporosis
•Rheumatoid arthritis
•Scoliosis
•Spondylolisthesis
•Depression
•Stress
Inguinal Hernia
• Surgical repair of an inguinal hernia consists of either
an open or a closed surgical technique.
• The open technique consists of opening the inguinal
canal, reducing the hernia, and reinforcing the floor
of the inguinal canal with a synthetic mesh.
• With the closed technique, the surgeon uses a
laparoscope to introduce the tools and mesh
through puncture holes to reduce the herniation
and reinforce the posterior wall of the inguinal
canal.
• Heavy manual labor workers are most common
recipients of this procedure.
Recovery
• Follow up occurs 1 week after surgery with limited
activities until that time.
• Avoid lifting more than 10 pounds for 4 weeks and
excessive bending or twisting for 1-2 weeks following
surgery.
• Walking is strongly encourage as soon as possible after
procedure. Successful hernia repair is achieved by
reducing factors that contribute pressure such as cough,
constipation, and repairing the defect so that the
incision line remains free of tension.
• Surgical treatment of uncomplicated hernias usually
results in complete recovery within a period of up to 6
weeks.
Return to Work
• Job Classification
RTW Min/Max
• Sedentary Work
5 days – 2 weeks
• Light Work
5 days – 2 weeks
• Medium Work
2 weeks – 4 weeks
• Heavy Work
4 weeks – 6 weeks
• Very Heavy Work
4 weeks – 8 weeks
One more thing!
• Remember everyone copes with injury, illness and
pain differently. It is important to understand a
person’s mental status can directly affect their
recovery.