The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 6

Scientific Articles | March 21, 2012

Disability, Impairment, and Physical Therapy Utilization After Arthroscopic Partial Meniscectomy in Patients Receiving Workers’ Compensation

John Di Paola, MD¹

¹ Occupational Orthopedics, LLC, 6464 S.W. Borland Road, Suite C-4, Tualatin, OR 97062. E-mail address: johndipaola@occortho.com

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Investigation performed at Occupational Orthopedics, LLC, Tualatin, OregonA commentary by Mark R. Hutchinson, MD, is linked to the online version of this article at jbjs.org.

Disclosure: The author did not receive payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. He, or his institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. The author has not had any other relationships, nor has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am, 2012 Mar 21;94(6):523-530. doi: 10.2106/JBJS.K.00076

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Abstract

Background:

The treatment of meniscal tears in injured workers is associated with less favorable outcomes and higher utilization of clinical services. It was hypothesized that patients receiving Workers’ Compensation who undergo arthroscopic meniscectomy can have excellent outcomes with physical therapy utilization below the national best-practices benchmarks.

Methods:

The records of 155 injured workers who had undergone 164 primary arthroscopic meniscectomies were reviewed at least one year following claim closure. The time to release to unrestricted full work duty and the number of postoperative physical therapy visits were compared between the study group (managed with a protocol-driven, independent exercise program) and the control group (managed with traditional outpatient physical therapy). The traditional therapy regimen was implemented by means of a written referral stating general goals (knee range of motion, strength, and function) and recommending a range or a maximum number of visits to be attended. Patients in the study group received a written referral specifying the exact number of visits that were approved, a kit containing exercise equipment with a booklet illustrating twenty-five exercises, and a prescribed rehabilitation protocol outlining the philosophy, expected subjective and functional outcomes, and specific objective weekly goals.

Results:

The median number of physical therapy visits per patient was 40% lower in the study group than in the control group (six compared with ten; p < 0.001). There was no difference between the study group and the control group with regard to the permanent partial disability rate (0% compared with 4.3%; p = 0.076). Following arthroscopic meniscectomy, there was no significant difference between the study group and the control group in terms of the time to release to light duty, the time to release to full duty, the time to claim closure, or the rate of impairment.

Conclusions:

The implementation of a structured, independent exercise protocol appears promising as a method to reduce physical therapy utilization to levels below the national best-practices benchmarks without negatively impacting impairment and disability rates for patients receiving Workers’ Compensation who undergo arthroscopic meniscectomy.

Level of Evidence:

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | Appendix

Arthroscopic partial meniscectomy is the most common surgical intervention performed by orthopaedic surgeons in the United States¹, with >650,000 procedures being performed annually². Meniscal tears are a frequent workplace injury, with arthroscopic partial meniscectomy (meniscectomy) representing the most frequent orthopaedic surgical procedure performed on injured workers in the United States³.

Injury-specific variables that have been shown to adversely affect the outcomes of meniscectomy have included a worse preoperative Short Form-36 (SF-36) functional health status score, osteoarthritis, a greater size of meniscal resection, a degenerative-type meniscal tear, location of the tear in the lateral meniscus, valgus knee alignment, chondromalacia, ligamentous instability, older age, a higher body mass index, simultaneous medial and lateral meniscectomy, prior knee surgery, and Workers’ Compensation status^4,5.

Less favorable outcomes have been reported following arthroscopic meniscectomy when patients receiving Workers’ Compensation have been compared with those not receiving Workers’ Compensation^4-6. A meta-analysis of 211 studies demonstrated that a Workers’ Compensation claim was associated with a higher rate of poor outcomes after a wide variety of surgical procedures⁶. The effect of a Workers’ Compensation claim was significant, clinically important, and consistent among studies evaluating the outcomes of various surgical procedures in diverse jurisdictions and geographic locations⁶.

Ferkel et al.⁴ reported that forty-six patients receiving Workers’ Compensation who underwent meniscectomy had had a significant increase in poor functional results in comparison with seventy-seven patients with non-work-related injuries (p < 0.001). Only 28% of patients returned to their original job without restrictions, and 17% were unable to return to work at all. Katz et al.⁵ compared twelve patients receiving Workers’ Compensation who underwent meniscectomy with ninety-three patients who had non-work-related injuries and, with use of multivariate analysis, identified Workers’ Compensation as the strongest predictor of poor outcomes after meniscectomy. The present study was conducted in an orthopaedic private practice that exclusively manages injured workers, providing the opportunity to evaluate a pure population of patients receiving Workers’ Compensation who underwent meniscectomy. To my knowledge, based on a PubMed literature search, the present report describes the largest study of meniscectomy in patients receiving Workers’ Compensation to date.

Indemnity costs related to nonmedical benefits resulting from the failure of the patient to return to full unrestricted duty in his or her job at injury (permanent partial disability) can greatly magnify the financial impact of the claim on the worker, the insurance carrier, the employer, and the Workers’ Compensation system⁷. Permanent partial disability is the most costly area of cash benefits paid by Workers’ Compensation programs directly to workers, but it has recently been eclipsed by a rise in medical costs⁸. The annual average rate of increase in Workers’ Compensation medical costs, primarily driven by increasing utilization of services⁹, has more than doubled since 1995 and in most years was over twice the rate of increase of the Medical Consumer Price Index^3,10.

The overutilization of physical therapy is the focus of national attention among Workers’ Compensation stakeholders^3,11. Physical medicine consistently ranks as a major driver of Workers’ Compensation medical costs nationwide, constituting approximately 50% of all treatments per claim. Physical therapy treatment costs increased by 61% from 1996 through 2003, primarily driven by a 32% increase in the number of visits per claim³. Therapeutic exercise ranks as the most frequent physical therapy treatment provided to injured workers^3,11. Despite attempts to control utilization by the implementation of experience-based¹² or consensus guidelines¹³, the effectiveness of this approach in modifying provider treatment patterns¹⁴ and reducing overall claim costs¹¹ has been questioned.

The purpose of the present study was to evaluate the ability of physicians to effectively reduce physical therapy utilization without negatively impacting disability or impairment rates by introducing standardized protocol-driven rehabilitation emphasizing independent exercise for injured workers following meniscectomy. It was hypothesized that controlling utilization would favorably impact factors that drive total claim costs without negatively affecting permanent partial disability and impairment at the time of claim closure. The number of postoperative physical therapy visits was measured to determine the effectiveness of the protocol on controlling utilization and not as a treatment outcome.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | Appendix

All patients with Workers’ Compensation claims that had been accepted only for work-related meniscal tears who were managed with meniscectomy by the author from 2003 through 2007, with a minimum duration of follow-up of two years after surgery and one year after claim closure, were evaluated for inclusion in this study. Two hundred and twelve meniscectomies in 197 patients were performed during that time. Six patients with associated injuries or comorbidities that prevented unrestricted participation in the rehabilitation protocol were excluded; this group included two patients with simultaneous ligament reconstruction, two with simultaneous microfracture, one with simultaneous osteochondral autograft transfer surgery, and one with meningitis and pneumonia. Six patients who had sustained a retear of the meniscus after primary meniscectomy and two patients who had had prior anterior cruciate ligament (ACL) reconstruction were eliminated from the study. Eighteen patients for whom there were insufficient data to confirm the exact number of postoperative physical therapy visits that were actually attended and ten patients who chose not to attend physical therapy visits were eliminated from consideration, leaving 164 meniscectomies in 155 patients available for inclusion in the study. All patients had open Workers’ Compensation claims, no ligament instability, and no contraindications to immediate progressive weight-bearing following arthroscopic knee surgery. The study was approved by the Legacy Health System institutional review board and was accomplished by means of a retrospective chart review, at a minimum of two years following surgery and one year following claim closure, of patients in a private orthopaedic practice that was engaged exclusively in the management of injured workers.

The control group was identified by the author on the basis of a review and analysis of the meniscectomies performed from January 1, 2002, through December 31, 2003. A traditional physical therapist-assisted rehabilitation program consisting of progressive weight-bearing through one week postoperatively with subsequent progression of knee range of motion, passive assisted exercise, active range of motion, and resistive exercises was utilized. Treatment was implemented by means of a written physician referral indicating the surgical procedure performed, stating general goals (knee motion, lower extremity strength, and resumption of activity), and recommending a range or a maximum number of visits to be attended over thirty days. The specific exercises, modalities, goals, number of visits scheduled, and basic structure of the rehabilitation program implemented were at the discretion of the individual therapist. The decision to continue therapy was primarily influenced by the therapists’ progress report, which contained recommendations for further treatment and often was received and signed by the physician before or after the patient was actually seen for follow-up. The physician's signature acknowledging receipt of the progress report for the treatment to date could also serve as authorization for further treatment. The overall therapy utilization rates for the control group at the time of review were observed to be below the Official Disability Guidelines, which document the median utilization of twenty-four physical therapy visits over sixteen weeks¹².

A motivation for this study was the observation that many patients developed overdependency on supervised physical therapy because they lacked the knowledge, confidence, and equipment needed to independently perform fundamental rehabilitative exercises. The requirement to attend multiple physical therapy appointments sometimes negatively impacted workplace relationships and could have resulted in lost wages when patients left work to attend therapy.

Beginning on January 1, 2004, the study protocol was implemented, targeting the utilization of six physical therapy visits over three weeks immediately following meniscectomy in patients with stable knees who had no contraindications to progressive weight-bearing as tolerated. Patients in the study group received a written referral specifying the exact number of visits that were approved within a thirty-day time frame based on the prescribed rehabilitation protocol, which outlined the treatment philosophy, expected subjective and objective functional outcomes, and specific weekly activity goals (see Appendix). A kit containing exercise equipment and a booklet illustrating twenty-five exercises (the FLEX Knee Therapy Kit; Top Shelf Orthopedics, Tracy, California) and a reusable hot/cold pack were given to each patient to implement the protocol (Fig. 1) (see Appendix). The decision to continue therapy was highly influenced by the patient's confidence that he or she had mastered the program and confirmation by the surgeon that the patient had met the functional and objective goals of the protocol. If more therapy was needed, the number and frequency of the visits were agreed on by the patient and the surgeon, who provided a new referral form. Therapist progress notes were processed with a stamp stating that only additional visits specifically designated on the physician's referral form were authorized. Therapists were encouraged to contact the surgeon so that interventions tailored to each patient's needs or more visits could be added as needed. The failure of the patient to meet objective, functional, and subjective recovery benchmarks alerted providers to the need for modifications or additions to the therapy regimen. Patients were offered additional visits until they demonstrated competency in independent rehabilitation, appropriate progress in reaching predetermined treatment benchmarks, and confidence in their ability to return to preinjury activities.

Fig. 1

Photograph showing a knee exercise kit.

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Six therapy providers who frequently managed injured workers were designated as major physical therapists and provided treatment following 121 meniscectomies. Prior to the implementation of the study, personal instruction was given to the major therapists in the rationale for the independent protocol and the importance of the Stay at Work/Return to Work⁹ principles, which describe the physical, social, and financial benefits for workers who remain engaged in productive work. The purpose was to educate therapists that workplace activities should be viewed as a beneficial adjunct to the rehabilitation process. A diverse group of twenty-two other therapy clinics were utilized because of patient preference, insurance panel requirements, or geographic considerations. These therapists provided therapy following forty-three meniscectomies during the present study and were designated as the minor therapists. No special instruction was offered to these therapists prior to implementation of the study. There was no difference between the major and minor therapists in terms of the referral process or the protocol prescribed.

Impairment was determined with use of the American Medical Association's Guides to the Evaluation of Permanent Impairment, Fifth Edition¹⁵, and utilization targets were benchmarked with use of the Official Disability Guidelines¹² because these two references are widely relied on in various states’ Workers’ Compensation systems. Permanent partial disability was defined as any permanent activity restriction placed on the worker at the time of claim closure, even if the worker returned to the same job with the same employer with or without accommodations¹⁶.

From January 1, 2004, through December 31, 2007, all patients with primary meniscal tears in knees with stable ligaments who were capable of performing the rehabilitative protocol were included in the present study to eliminate selection bias. At least one year following claim settlement and two years following surgery, data were collected by means of retrospective chart review. The number of postoperative physical therapy visits, functional status (disability), and impairment ratings were recorded for each of the 164 meniscectomies, with a comparison carried out between the control and study groups.

Statistical Methods

For comparisons between the two groups, the level of significance was set at p ≤ 0.05. A two-tailed Student t test was used for continuous variables. The Fisher exact test and the chi-square test were utilized for nominal data. Crude odds ratios and 95% confidence intervals (CI) were calculated when appropriate.

The primary dependent variables of interest were permanent partial disability and impairment. The independent variable was the implementation of the accelerated independent exercise protocol (the control group compared with the study group), but, because therapy was ordered by the author, there was a substantial potential for bias. The objective was to determine whether the new protocol would significantly reduce the number of required postoperative physical therapy treatments and whether this would have a significant positive or negative impact on the rates of impairment and return to unrestricted full duty.

Other variables that were examined included age, sex, body mass index, the type of physical therapy provider (major or minor), the number of weeks from injury to surgery, the number of weeks from surgery to return to work, and the number of weeks from surgery to claim closure. Other findings at the time of surgery that could potentially impact outcomes were recorded and analyzed, including arthroscopic findings of chondromalacia, osteochondral defect, synovitis/plica syndrome, and partial acute or chronic ACL injury without clinical or functional instability. The description and physical requirements of each patient's job at the time of the injury were recorded and classified as sedentary, light, medium, heavy, or very heavy, according to the U.S. Department of Labor's Dictionary of Occupational Titles, Fourth Edition¹⁷.

Source of Funding

There are no financial incentives available to Workers’ Compensation providers based on their utilization patterns, and by statute all injured workers have free choice in selecting treating physicians. The study was not endorsed or supported in any way by any manufacturers, insurers, or government agencies. The author had no financial interest in the exercise kits provided to patients, and there were no external funding sources for this study.

Results

Introduction | Materials and Methods | Results | Discussion | Appendix

The present study included 155 injured workers (164 primary arthroscopic meniscectomies) with an average age of 43.6 years (range, twenty-three to sixty-seven years) at the time of surgery. One hundred and forty meniscectomies (85.4%) were performed in men, and twenty-four (14.6%) were performed in women. The mean duration of symptoms between the time of the injury and the date of surgery was 4.5 months (range, one to nineteen months). Of the 155 patients with complete data for review, 147 had a single primary tear, seven had two primary tears (six had a bilateral tear and one had a primary tear plus a new injury to the same knee), and one had three primary tears (a bilateral tear plus a new tear), for a total of seventeen additional primary meniscectomies (see Appendix). Each primary tear represents a discrete injury mechanism leading to a surgically confirmed meniscal tear, the performance of a meniscectomy followed by a complete recovery, and claim closure. Two patients underwent meniscectomy for multiple separate tears over time and were included in both the study group and the control group (see Appendix).

Return to Work

To determine the impact that implementing structured physical therapy protocols had on return to full-duty work, all 155 patients (164 meniscectomies) were prescribed physical therapy and were followed to claim closure. Seventy (42.7%) of the 164 meniscectomies had been performed in the historical cohort (control group), and ninety-four (57.3%) had been performed in the group managed with the independent exercise protocol (study group). A data analysis that was performed to determine the impact on claim status demonstrated no significant difference between the control group and the study group in terms of the number of weeks following meniscectomy that it took to return to light duty, full duty, or claim closure. There was no difference between the study group and the control group in terms of the permanent partial disability rate (0% compared with 4.3%; p = 0.08, Fisher exact test) (Table I).

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TABLE I Description of Results

Factor	Study Group (N = 94)	Control Group (N = 70)	Combined Group (N = 164)	P Value
No. of weeks to light duty				0.17*
Median	2.0	2.0	2.0
Mean	2.2	2.6	2.2
No. of weeks to full duty†				0.76*
Median	9.5	9.0	9.0
Mean	10.9	11.5	11.2
No. of weeks to closure				0.45*
Median	15.0	15.0	15.0
Mean	16.6	20.3	18.2
Permanent partial disability rate (%)	0%	4.3%	1.8%	0.08‡

*Wilcoxon rank-sum test.
†N = 161 (excludes three meniscectomies that resulted in permanent partial disability).
‡Fisher exact test.

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TABLE I Description of Results

Factor	Study Group (N = 94)	Control Group (N = 70)	Combined Group (N = 164)	P Value
No. of weeks to light duty				0.17*
Median	2.0	2.0	2.0
Mean	2.2	2.6	2.2
No. of weeks to full duty†				0.76*
Median	9.5	9.0	9.0
Mean	10.9	11.5	11.2
No. of weeks to closure				0.45*
Median	15.0	15.0	15.0
Mean	16.6	20.3	18.2
Permanent partial disability rate (%)	0%	4.3%	1.8%	0.08‡

*Wilcoxon rank-sum test.
†N = 161 (excludes three meniscectomies that resulted in permanent partial disability).
‡Fisher exact test.

Associated Intra-Articular Pathology

Forty-seven meniscectomies (28.7%) were performed in patients who had had an isolated meniscal tear with no other intra-articular pathology identified at the time of primary surgery. One hundred and seventeen meniscectomies (71.3%) were performed in patients who had had other intra-articular findings at the time of primary arthroscopic meniscectomy, including ACL sprains, synovitis/plica syndrome, and chondromalacia. The associated conditions either preexisted the work-related injury or were minor acute injuries that did not preclude the worker's ability to participate in an immediate weight-bearing rehabilitation program. The presence of an associated injury or preexisting pathology had no significant negative effect on the rate of permanent partial disability or the number of physical therapy visits required in comparison with the findings for patients with an isolated meniscal tear (chi-square test). Two (66%) of the three patients with permanent partial disability had an associated condition that was confirmed at the time of arthroscopy. No correlation between the presence of associated intra-articular injury or preexisting condition could be made because of the small sample size of patients with permanent partial disability.

Chondromalacia was the most frequently associated diagnosis noted at the time of meniscectomy. A retrospective review of operative notes and intraoperative arthroscopic photographs was used to characterize the chondromalacia by determining its location relative to the meniscal tear (same knee compartment, opposite compartment, or patellofemoral joint) (location), the maximum Outerbridge grade¹⁸ identified (grade), and the total number of compartments affected (involvement) in each knee. There was no difference between the study group and the control group in terms of the individual characteristics of the chondromalacia (i.e., location, grade, or degree of involvement) (Table II). A multivariate logistic regression model demonstrated that the combined effects of the characteristics (location, grade, and involvement) were not significantly associated with a patient being in the study group as compared with the control group (chi-square test [4df] = 3.75; p = 0.44).

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TABLE II Comparison of Meniscectomies in Patients with Chondromalacia (N = 103)*

Characteristic	Study Group (N = 54)	Control Group (N = 49)	P Value†
Location‡			0.86
Opposite knee compartment	5 (9.3%)	5 (10.2%)
Same knee compartment	44 (81.5%)	41 (83.7%)
Patellofemoral joint	5 (9.3%)	3 (6.1%)
Grade§			0.07
1	3 (5.6%)	6 (12.2%)
2	19 (35.2%)	8 (16.3%)
3	27 (50.0%)	33 (67.3%)
4	5 (9.3%)	2 (4.1%)
Involvement#			0.06
1	32 (59.3%)	24 (49.0%)
2	20 (37%)	16 (32.7%)
3	2 (3.7%)	9 (18.4%)

*The values are given as the number of meniscectomies.
†Fisher exact text.
‡Location of chondromalacia relative to compartment undergoing meniscectomy.
§Maximum Outerbridge grade of chondromalacia identified during meniscectomy.
#Number of compartments with chondromalacia.

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TABLE II Comparison of Meniscectomies in Patients with Chondromalacia (N = 103)*

Characteristic	Study Group (N = 54)	Control Group (N = 49)	P Value†
Location‡			0.86
Opposite knee compartment	5 (9.3%)	5 (10.2%)
Same knee compartment	44 (81.5%)	41 (83.7%)
Patellofemoral joint	5 (9.3%)	3 (6.1%)
Grade§			0.07
1	3 (5.6%)	6 (12.2%)
2	19 (35.2%)	8 (16.3%)
3	27 (50.0%)	33 (67.3%)
4	5 (9.3%)	2 (4.1%)
Involvement#			0.06
1	32 (59.3%)	24 (49.0%)
2	20 (37%)	16 (32.7%)
3	2 (3.7%)	9 (18.4%)

Under the current Oregon Workers’ Compensation Division rules, workers undergoing a partial meniscectomy automatically receive a scheduled impairment of 5%¹⁶. With use of the methods required by the American Medical Association's Guides to the Evaluation of Permanent Impairment, Fifth Edition, a partial meniscectomy results in a diagnosis-based impairment equal to 2% of the lower extremity¹⁵. There were no cases in which a reduction of strength or knee motion was apportioned to the meniscal tear or its treatment on the basis of the Oregon Workers’ Compensation Law. Because there was no objectively measurable worsening of the preexisting conditions attributable to the meniscal injury or its treatment, these preexisting conditions were not apportioned to the work injury. Associated acute conditions did not produce any separately ratable impairment.

No significant difference was seen between the study group and the control group with regard to dependent variables at the time of surgery, including age, sex, body mass index, U.S. Department of Labor job classification, the number of cases of chondromalacia, or the type of physical therapy provider (major or minor) (Table III). The time from surgery to light duty, the time from surgery to full duty, and the time from surgery to claim closure (in weeks) were not significantly different between the study group and the control group (Table I).

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TABLE III Comparison of Study Group with Control Group (N = 164)

Characteristic	Study Group (N = 94)	Control Group (N = 70)	Test	P Value
Age at surgery*(yr)	43.0 ± 10.5	44.3 ± 9.4	t₁₆₂ = 0.81	0.42
Age group†			χ²(2) = 2.5	0.29
30 to <40 yr	39 (41.5%)	21 (30.0%)
40 to <50 yr	28 (29.8%)	27 (38.6%)
≥50 yr	27 (28.7%)	22 (31.4%)
Male sex†	81 (86.2%)	59 (84.3%)	χ²(1) = 0.11	0.74
Body mass index
Mean*(kg/m2)	32.0 ± 6.8	31.8 ± 6.5	t₁₄₆ = 0.23	0.82
Missing data†	7 (7.4%)	9 (12.9%)	χ²(1) = 1.33	0.25
U.S. Department of Labor job classification†‡			Fisher exact§	0.41
Sedentary	0 (0.0%)	1 (1.4%)
Light	2 (2.1%)	5 (7.2%)
Medium	26 (27.7%)	17 (24.6%)
Heavy	46 (48.9%)	33 (47.8%)
Very heavy	20 (21.3%)	13 (18.8%)
Chondromalacia†	54 (57.4%)	49 (70.0%)	χ²(1) = 2.7	0.10
Therapy provider†			χ²(1) = 1.7	0.19
Major	73 (77.7%)	48 (68.6%)
Minor	21 (22.3%)	22 (31.4%)

*The values are given as the mean and standard deviation.
†The values given are the number of meniscectomies.
‡Data were missing for one meniscectomy in the control group; these tests were based on ninety-four meniscectomies in the study group and sixty-nine meniscectomies in the control group.
§The Fisher exact test was used as an alternative to the chi-square test because of small counts.

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TABLE III Comparison of Study Group with Control Group (N = 164)

Characteristic	Study Group (N = 94)	Control Group (N = 70)	Test	P Value
Age at surgery*(yr)	43.0 ± 10.5	44.3 ± 9.4	t₁₆₂ = 0.81	0.42
Age group†			χ²(2) = 2.5	0.29
30 to <40 yr	39 (41.5%)	21 (30.0%)
40 to <50 yr	28 (29.8%)	27 (38.6%)
≥50 yr	27 (28.7%)	22 (31.4%)
Male sex†	81 (86.2%)	59 (84.3%)	χ²(1) = 0.11	0.74
Body mass index
Mean*(kg/m2)	32.0 ± 6.8	31.8 ± 6.5	t₁₄₆ = 0.23	0.82
Missing data†	7 (7.4%)	9 (12.9%)	χ²(1) = 1.33	0.25
U.S. Department of Labor job classification†‡			Fisher exact§	0.41
Sedentary	0 (0.0%)	1 (1.4%)
Light	2 (2.1%)	5 (7.2%)
Medium	26 (27.7%)	17 (24.6%)
Heavy	46 (48.9%)	33 (47.8%)
Very heavy	20 (21.3%)	13 (18.8%)
Chondromalacia†	54 (57.4%)	49 (70.0%)	χ²(1) = 2.7	0.10
Therapy provider†			χ²(1) = 1.7	0.19
Major	73 (77.7%)	48 (68.6%)
Minor	21 (22.3%)	22 (31.4%)

The median number of physical therapy visits was four fewer (95% CI, 2.0 to 6.0 fewer) for the study group than for the control group, and this difference was not influenced by age, type of physical therapy provider (major or minor), U.S. Department of Labor job classification, or body mass index (Table IV). More strenuous jobs were associated with a greater number of visits, but the median number of visits remained four fewer in the study group compared with the control group, regardless of the U.S. Department of Labor job classification. There was no significant difference between the study group and the control group with regard to the median number of physical therapy visits among women (p = 0.71). Because 85.4% of the meniscectomies in the present study were performed in men, the conclusion remains that the study group utilized a median of six physical therapy visits whereas the control group utilized a median of ten physical therapy visits (p < 0.001).

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TABLE IV Median Number of Physical Therapy Visits (N = 164 Meniscectomies)

Characteristic	Study Group (N = 94)*	Control Group (N = 70)*	Test	P Value
Protocol	6 ± 0.5	10 ± 0.8	t₁₆₂ = 4.20	<0.001
Sex
Male	6 ± 0.6	10 ± 0.9	t₁₆₀ = 3.58	<0.001
Female	7 ± 1.9	6 ± 1.8	t₁₆₀ = 0.38	0.71
Age at surgery			t₁₆₁ = 4.02	<0.001
30 to <40 yr	6 ± 0.8	10 ± 1.1
40 to <50 yr	6 ± 1.0	10 ± 1.1
50 to <60 yr	6 ± 1.0	10 ± 1.1
Physical therapy provider			t₁₆₁ = 3.98	<0.001
Major	6 ± 0.6	10 ± 0.9
Minor	6 ± 1.1	10 ± 1.1
U.S. Department of Labor job classification			t₁₅₇ = 3.39	0.001
Sedentary	2 ± 1.2	6†
Light	4 ± 2.8	8 ± 2.7
Medium	6 ± 1.2	10 ± 1.4
Heavy	6 ± 0.8	10 ± 1.1
Very heavy	7 ± 1.5	11 ± 1.6
Body mass index			t₁₆₁ = 4.03	<0.001
<25 kg/m²	6 ± 1.6	10 ± 1.7
≥25 kg/m²	6 ± 0.6	10 ± 0.8

*The values are given as the median number of physical therapy visits and the standard error.
†The standard error could not be reliably estimated for this value.

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TABLE IV Median Number of Physical Therapy Visits (N = 164 Meniscectomies)

Characteristic	Study Group (N = 94)*	Control Group (N = 70)*	Test	P Value
Protocol	6 ± 0.5	10 ± 0.8	t₁₆₂ = 4.20	<0.001
Sex
Male	6 ± 0.6	10 ± 0.9	t₁₆₀ = 3.58	<0.001
Female	7 ± 1.9	6 ± 1.8	t₁₆₀ = 0.38	0.71
Age at surgery			t₁₆₁ = 4.02	<0.001
30 to <40 yr	6 ± 0.8	10 ± 1.1
40 to <50 yr	6 ± 1.0	10 ± 1.1
50 to <60 yr	6 ± 1.0	10 ± 1.1
Physical therapy provider			t₁₆₁ = 3.98	<0.001
Major	6 ± 0.6	10 ± 0.9
Minor	6 ± 1.1	10 ± 1.1
U.S. Department of Labor job classification			t₁₅₇ = 3.39	0.001
Sedentary	2 ± 1.2	6†
Light	4 ± 2.8	8 ± 2.7
Medium	6 ± 1.2	10 ± 1.4
Heavy	6 ± 0.8	10 ± 1.1
Very heavy	7 ± 1.5	11 ± 1.6
Body mass index			t₁₆₁ = 4.03	<0.001
<25 kg/m²	6 ± 1.6	10 ± 1.7
≥25 kg/m²	6 ± 0.6	10 ± 0.8

*The values are given as the median number of physical therapy visits and the standard error.
†The standard error could not be reliably estimated for this value.

Discussion

Introduction | Materials and Methods | Results | Discussion | Appendix

This study demonstrates that the implementation of a structured, independent exercise protocol utilizing significantly fewer physical therapy visits can be accomplished without negatively impacting impairment or disability rates for patients receiving Workers’ Compensation who have undergone arthroscopic partial meniscectomy. The timeliness of release to work and claim closure were equivalent between the control group and the study group and remained consistent with national best-practices guidelines¹², suggesting that there was no unfavorable impact on indemnity costs by the new protocol-driven treatment.

Providing more services does not necessarily ensure better results and may have either no effect or a negative effect on functional or financial outcomes. Some investigators have found that supervised physical therapy is essential to successful functional outcomes following partial meniscectomy^19-21, whereas others have demonstrated that unsupervised home rehabilitation produced equally good functional outcomes with a substantial reduction in medical costs when compared with supervised physical therapy^22,23. Studies in Texas demonstrated a wide variation in the provision of physical medicine services to patients receiving Workers’ Compensation within that state, with high-volume providers utilizing over six times the median number of visits for therapeutic exercise^24,25. Over a wide range of diagnoses, the studies showed that Texas workers, despite undergoing more treatments (diagnostic testing, physical therapy, and surgery) for longer periods of time, had more difficulty returning to work after their injuries and were not more satisfied with the medical care that they received compared with workers in other states²⁶.

Providers should be able to demonstrate a treatment's effectiveness by identifying objective and quantitative improvement in the patient's function and ability to return to work to reduce overutilization of services that impact the total costs of Workers’ Compensation claims^14,25. Medical evidence-based, protocol-driven physical therapy may be a first step toward identifying the most effective levels of utilization to positively impact the quality and efficiency of treatment for injured workers undergoing arthroscopic meniscectomy.

The retrospective design of this study had several limitations. Data were not available regarding all confounding variables shown to potentially affect the outcomes of Workers’ Compensation claims or all factors associated with less favorable outcomes following meniscectomy. Using a historical cohort rather than a concurrent randomized control group introduced a potential source of selection bias into the study. Patients were released to full duty, but whether they actually returned to the job that they had performed at the time of the injury could have been influenced by workplace variables that were not documented in the medical records. Impairment-rating examinations involve a process that carries an inherent observer bias²⁷ that could be potentially magnified by their being performed by the author. Although the prescribing of physical therapy visits was protocol-driven, the number of visits ordered was ultimately decided by the author, introducing another source of bias. The study population was derived from the private practice of a single surgeon who managed only patients receiving Workers’ Compensation, with no comparison to a general patient population. Workers’ Compensation laws, insurance carriers, and the industrial/occupational mix vary from state to state, which could affect outcomes. The focus of the study was confined to reflecting the impact of a new treatment approach on the outcomes affecting the total costs of a Workers’ Compensation claim, and no attempts were made to recontact patients to determine long-term functional outcomes subsequent to claim closure.

The implementation of a structured, independent exercise protocol appears promising as a method to reduce physical therapy utilization to levels below national best-practices benchmarks without negatively impacting impairment and disability rates in injured workers undergoing arthroscopic meniscectomy. Further testing of this hypothesis with a prospective randomized study is warranted, which would potentially produce information of value toward developing an approach to injured worker care that would consistently produce results comparable with other patient demographic groups.

Appendix

Introduction | Materials and Methods | Results | Discussion | Appendix

A table showing the distribution of meniscal tears, a sample therapy request form, a sample physical medicine treatment plan, and the booklet illustrating the exercises are available with the online version of this article as a data supplement at jbjs.org.

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Topics

worker's compensation ; rehabilitation ; knee meniscus tears ; disability ; partial meniscectomy of knee

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These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

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John Di Paola; Disability, Impairment, and Physical Therapy Utilization After Arthroscopic Partial Meniscectomy in Patients Receiving Workers’ Compensation. The Journal of Bone & Joint Surgery. 2012 Mar;94(6):523-530.

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