New York State Medical Treatment Guidelines for
History Taking and Physical Examination 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 History Taking and Physical Examination.

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.

History Taking and Physical Examination for Knee Injury

Physical examination and history-taking lay the groundwork for and direct the progression of diagnostic and therapeutic procedures.

When findings from clinical evaluations and those from other diagnostic techniques do not agree, preference should be given to the objective clinical findings. The following should be appropriately documented in the medical records:

History of Present Injury for Knee Injury

• Information about the origin and course of symptoms, as well as any symptoms that may come from postural or functional adaptation to the knee injury, are all part of the mechanism of injury;

• Relationship to work: This comprises an assessment of the likelihood that the ailment or injury is caused by the job;

• Prior injuries to the same location, both occupational and non-occupational, including any prior bracing devices and particular prior treatment;

• A history of pain while going up or down stairs, locking, clicking, giving way, crepitation, popping, swelling (present description of onset and volume);d giving way.

• The capacity to carry out necessary everyday tasks and job responsibilities.

• Aside from the knee, other areas of the body might also contribute to the exacerbation or amelioration of arthritis symptoms.

Past History for Knee Injury

• Past medical history includes, but is not limited to, neoplasm (or recurrence), gout/pseudogout, infections and significant knee femur and/or leg trauma;

• A review of systems should be conducted to identify signs or symptoms related to the following systems: constitutional symptoms; eyes; ears, nose, mouth and throat; cardiovascular;

• Respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary/breast. Neurological, psychiatric, endocrine and hematologic/lymphatic conditions can be treated by a clinician.

• Allergic/immunologic issues are also treatable by specialists in this field. A doctor will consider the patient’s underlying condition when deciding on which system of medicine to target.

• Military service, vocational pursuits, and recreational activities.

• Prior imaging studies have shown that.

• Past medical history.

Physical Examination for Knee Injury

When examining a joint, it is important to examine the joint above and below the affected area. Physical examinations should include accepted tests and exam techniques applicable to the joint or area being examined, including:

Here are some things to be on the lookout for during visual inspection:

• Palpation

• Range of motion, or the amount and quality of movement a person can do, is an important factor in determining health.

• The nurse evaluates for muscle atrophy and fasciculations.

• Joint stability is important in all athletic endeavors.

• A doctor will check to see if your kneecap is displaced or abnormally positioned.

• If the injury affects the integrity of distal circulation and sensory and motor functions, it may be more difficult to heal.

• A full neurological exam should include muscle atrophy, gait abnormality and other possible conditions.

Red Flags for Knee Injury

Certain findings, “red flags,” can indicate a serious medical condition. Your doctor will ask about red flags when evaluating your knee injury. These may include fractures, dislocations, and ligamentous tears; infections or inflammations; neurological or vascular compromise including compartment syndrome; and histories of trauma, including but not necessarily limited to serious motor vehicle crashes, crush injuries, or falls from heights.

Further evaluation/consultation or urgent/emergency intervention may be indicated based on the presence of red flags.

What our office can do if you have workers compensation injuries

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.