New York State Medical Treatment Guidelines for
Foot Ulceration in workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Foot Ulceration.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Physical Examination for Foot Ulceration

It is important to note an ulcer’s size, depth, location, and overall health. Examine the area for exudate, odour, sinus tracts, tunnelling, undermining, necrosis or eschar formation, infection, and evidence of healing (granulation and epithelialization). Examine the wound’s margins and the surrounding areas for induration, infection, and inflammation. Determine the stage of each ulcer.

Foot sensation as well as bone and joint abnormalities need to be thoroughly evaluated. It is beneficial to assess capillary refill and the perfusion of the foot and ankle, especially the dorsalis pedis and posterior tibial pulses. Shoes should be examined for sound construction, comfort and support, and the absence of projecting, pointed, or abrasive elements.

Wagner Grading System:

Grade 0 – No ulcer in a high-risk patient

Grade 1 – A superficial ulcer that affects the entire thickness of the skin but not the underlying tissues

Grade 2 – Deep ulcer that penetrates down to the muscle and ligaments but does not involve the bone or produce an abscess

Grade 3 – deep ulcer frequently accompanied by cellulitis or an abscess
Osteomyelitis

Grade 4 – regional gangrene

Grade 5 – a severe case of gangrene affecting the entire foot

Diagnostic Studies for Foot Ulceration in workers compensation patients

1. X-Rays for Diagnostic of Foot Ulceration

   X-Rays for Diagnostic of Foot Ulceration is recommended for individuals who are unsure of the involvement of the bone, specific worries around osteomyelitis.

    

2. Bone Scans Foot Ulceration

   Bone Scans Foot Ulceration is recommended for people who doubt their interaction with bones, unreliable x-rays.

Medications for Foot Ulceration

Non-steroidal anti-inflammatory drugs (NSAIDs) and/or acetaminophen for pain. Due to the tendency for the join to be denervated, control are frequently not required but are advised if necessary.

Ibuprofen, naproxen, or other NSAIDs from an earlier generation are suggested as first-line treatments for the majority of patients. For patients who are not candidates for NSAIDs, acetaminophen (or the analogue paracetamol) may be a viable alternative, even if the majority of research indicates it is just marginally less effective than NSAIDs.

There is proof that NSAIDs are less dangerous and just as effective in treating pain as opioids, such as tramadol.

1. Non-Steroidal Anti-Inflammatory Drugs for Foot Ulceration

   Non-Steroidal Anti-Inflammatory Drugs for Foot Ulceration is recommended for the treatment of non-healing, infected ulcers that are acute, subacute, chronic, or postoperative Acute, subacute, chronic, or postoperative pain are all indications. NSAIDs are advised as a therapy. First, try over-the-counter (OTC) medications to see whether they work.

   Frequency/Duration: Many Patients may find it reasonable to use as needed.

   Indications for Discontinuation: Pain relief, ineffectiveness, or the emergence of side effects that need stopping.

    

2. NSAIDs for Patients at High-Risk of Gastrointestinal Bleeding for Foot Ulceration

   NSAIDs for Patients at High-Risk of Gastrointestinal Bleeding for Foot Ulceration are recommended patients who are at a high risk of gastrointestinal bleeding should take misoprostol, sucralfate, histamine type 2 receptor blockers, and proton pump inhibitors concurrently.

   Indications: For patients who additionally have a high-risk factor profile, NSAID indications, cytoprotective drugs should be taken into consideration, especially if longer-term treatment is being considered. vulnerable patients include older people, people with a history of gastrointestinal bleeding, diabetes and cigarette smokers of cigarettes.

   Frequency/Dose/Duration: H2 blockers, misoprostol, sucralfate, and proton pump inhibitors are advised. dosage recommendations from the manufacturer. There aren’t typically thought to be any significant variations in effectiveness for stopping gastrointestinal bleeding.

   Indications for Discontinuation: Intolerance, the emergence of negative effects, or the stopping of NSAIDs.

    

3. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects for Foot Ulceration

   NSAIDs for Patients at Risk for Cardiovascular Adverse Effects for Foot Ulceration is recommended as aspirin or acetaminophen as the initial course of treatment seem to be the least harmful in terms of cardiovascular issues. If necessary, non-selective NSAIDs are recommended to COX-2-specific medications.

   To reduce the chance that an NSAID will negate the protective effects of low-dose aspirin in individuals receiving it for primary or secondary cardiovascular disease prevention, the NSAID should be taken at least 30 minutes after or eight hours before the daily aspirin.

    

4. Acetaminophen for Treatment of Acute, Subacute, or Chronic NonHealing and/or Infected Ulcers

   Acetaminophen for Treatment of Acute, Subacute, or Chronic NonHealing and/or Infected Ulcers ar recommended for the treatment of sudden, gradual, or persistent pain, especially those who should not take NSAIDs. All patients with pain, whether it is acute, subacute, or chronic, are candidates. and following surgery.

   Dose/Frequency: As per the manufacturer’s recommendations; can be used as required. Over four gm/day, there is evidence of liver toxicity.

   Indications for Discontinuation: resolution of discomfort, negative effects, or

   intolerance.

    

5. Opioids for Pain from Acute, Subacute, Chronic or Postoperative Foot Ulcer

   Opioids for Pain from Acute, Subacute, Chronic or Postoperative Foot Ulcer are recommended – Opioids may be used sparingly (for no longer than seven days) to treat a small number of patients who have severe foot ulcer-related pain. For some individuals who have just had surgery, it is also advised to use opioids sparingly for a few days (maximum seven days).

   Frequency/Dose/Duration: Frequency and dosage should follow the manufacturer’s instructions; they may be taken on a schedule or as needed. Short courses of a few days are often administered, followed by a weaning period to nocturnal use if necessary, before withdrawal. The average treatment course lasts a few days to a week. In general, it should be used as an additional form of pain relief to NSAIDs or acetaminophen to lessen the overall need for opioids and the resulting negative effects.

   Indications for Discontinuation: Inability to progress for more than a few weeks due to inadequate pain management with other treatments, such as NSAIDs, pain relief, intolerance, negative side effects, lack of benefits, or remission of pain

    

6. Antibiotics Foot Ulcer

   Antibiotics Foot Ulcer is recommended for the majority of infected and/or chronic ulcers. The selection of antibiotics should be tailored to the organism being predicted or grown.

Treatments for Foot Ulceration

Mobilization / Immobilization

1. Total Contact Casting for Foot Ulcers

   Total Contact Casting for Foot Ulcers is recommended for foot ulcers.

   Indications – Potential candidates include all patients with non-healing foot ulcerations.

    

2. Foot Waffle Support Brace

   Foot Waffle Support Brace is not recommended for patients with foot ulcers.

   Surgery of Foot Ulceration

    

3. Surgical Debridement to Treat Lower Extremity Ulcers

   Surgical Debridement to Treat Lower Extremity Ulcers is recommended for the treatment of lower extremity ulcers; particularly for devascularized, callus, wound edge tissue and foreign debris.

    

4. Hyperbaric Oxygen for Foot Ulcers

   Hyperbaric Oxygen for Foot Ulcers is recommended to cure some foot ulcers.Indications: More than three-month-old Wagner’s 2, 3, or 4 foot ulcer(s).

   Frequency: treatments for eight weeks, five days each week. 40 treatments at most; up to ten weeks.

What our office can do if you have Foot Ulceration due to workers compensation injury

We have the experience to help you with their workers compensation injuries. We understand what you are going through and will meet your medical needs and follow the guidelines set by the New York State Workers Compensation Board.

We understand the importance of your workers compensation cases. Let us help you navigate through the maze of dealing with the workers compensation insurance company and your employer.

We understand that this is a stressful time for you and your family. If you would like to schedule an appointment, please contact us so we will do everything we can to make it as easy on you as possible.