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Shoulder Injury

June 25, 2015

ILLINOIS WORKERS’ COMPENSATION COMMISSION
NOTICE OF 19(b) DECISION OF ARBITRATOR

Case #

Employee/Petitioner

Employer/Respondent

On 5/4/2011, an arbitration decision on this case was filed with the Illinois Workers’ Compensation Commission in Chicago, a copy of which is enclosed.
If the Commission reviews this award, interest of 0.10% shall accrue from the date listed above to the day before the date of payment; however, if an employee’s appeal results in either no change or a decrease in this award, interest shall not accrue.
A copy of this decision is mailed to the following parties:
1067 ANKIN LAW OFFICE LLC
162 W GRAND AVE SUITE 1810
CHICAGO, IL 80654

STATE OF ILLINOIS )
)SS.
COUNTY OF _____ )

ILLINOIS WORKERS’ COMPENSATION COMMISSION
ARBITRATION DECISION
19(b)

Case #

Employee/Petitioner

v. Consolidated Cases:

Employer/Respondent

An Application for Adjustment of Claim was filed in this matter, and a Notice of Hearing was mailed to each party. The matter was heard by the Honorable , Arbitrator of the Commission, in the city of Chicago, Illinois, on [DATE]. After reviewing all of the evidence presented, the Arbitrator hereby makes findings on the disputed issues checked below, and attaches those findings to this document.
DISPUTED ISSUES
A. Was Respondent operating under and subject to the Illinois Workers’ Compensation or Occupational Diseases Act?

B. Was there an employee-employer relationship?

B. Did an accident occur that arose out of and in the course of Petitioner’s employment by Respondent?

D. What was the date of the accident?

E. Was timely notice of the accident given to Respondent?

F. Is Petitioner’s current condition of ill-being causally related to the injury?

G. What were Petitioner’s earnings?

H. What was Petitioner’s age at the time of the accident?

I. What was Petitioner’s marital status at the time of the accident?

J. Were the medical services that were provided to Petitioner reasonable and necessary?
Has Respondent paid all appropriate charges for all reasonable and necessary medical services?

K. Is Petitioner entitled to any prospective medical care?

L. What temporary benefits are in dispute?

TPD Maintenance TTD
M. Should penalties or fees be imposed upon Respondent’?

N. Is Respondent due any credit?

O. Other

FINDINGS

On the date of accident, 06/07/10, Respondent was operating under and subject to the provisions of the Act.

On this date, an employee-employer relationship did exist between Petitioner and Respondent.

On this date, Petitioner did sustain an accident that arose out of and in the course of employment.

Timely notice of this accident was given to Respondent.

Petitioner’s current condition of ill-being is causally related to the accident.

In the year preceding the injury, Petitioner earned $24,818.04; the average weekly wage was $477.27.

On the date of accident, Petitioner was 30 years of age, married with 1 dependent children.

Respondent has not paid all reasonable and necessary charges for all reasonable and necessary medical services.

Respondent shall be given a credit of $7,363.59 for TTD, $ for TPD, $1,333.32 in a PPD Advance, and $ for other benefits, for a total credit of $8,696.91.

Respondent is entitled to a credit of $0.00 under Section 8(j) of the Act.

ORDER
Respondent shall pay Petitioner temporary total disability benefits of $317.86/week for 40-2/7 weeks, commencing June 8, 2010 through March 16, 2011 as provided in Section 8(b) of the Act. Respondent shall receive a credit for all temporary total disability benefits that have been paid to date.
Respondent shall pay reasonable and necessary medical services, pursuant to the medical fee schedule, of $5,003.08 to , $270.00 to , $1,832.00 to MRI, and $5,092.26 to Orthopedics, as provided in Sections 8(a) and 8.2 of the Act. Respondent shall be given a credit for any medical services that were previously paid for.
Respondent shall authorize Petitioner’s surgical procedure prescribed by Dr. Blair Rhode.
In no instance shall this award be a bar to subsequent hearing and determination of an additional amount of medical benefits or compensation for a temporary or permanent disability, if any.

RULES REGARDING APPEALS Unless a party files a Petition for Review within 30 days after receipt of this decision and perfects a review in accordance with the Act and Rules, then this decision shall be entered as the decision of the Commission.

STATEMENT OF INTEREST RATE If the Commission reviews this award, interest at the rate set forth on the Notice of Decision of Arbitrator shall accrue from the date listed below to the day before the date of payment; however, if an employee’s appeal results in either no change or a decrease in this award, interest shall not accrue.

____________________________________ _____________________________

Signature of Arbitrator Date

Attachment to Arbitrator Decision

STATEMENT OF FACTS:
Petitioner was employed by as a customer service representative. Petitioner testified that on June 7, 2010 she was checking in a passenger and as she lifted a 40 pound piece of luggage she immediately felt a pop in her left shoulder and neck area. Petitioner reported her injury and was sent to Medical Center.

Petitioner reported to on the date of accident. Petitioner complained of immediate pain on the top of her left shoulder and in her trapezius muscle as “[she] was lifting a 45 pound bag off the scale and throwing it off the belt.” An examination revealed tenderness of the superior aspect of the left shoulder and limited range of motion with pain on abduction. Also noted was palpation tenderness of the left trapezius muscle. Petitioner was diagnosed with a left shoulder strain and released to work with restrictions. Physical therapy and a MRI were also ordered. (PX 1) Petitioner testified that Respondent could not accommodate her restriction and she began to receive temporary total disability benefits.

On June 9, 2010, Petitioner returned to . Petitioner noted that her symptoms were improving. Petitioner reported pain on the posterior aspect of the left shoulder and left trapezius muscle. She described the pain as mild, aching, constant, worse after activity and worse to touch. The diagnosis remained the same as did the light duty restrictions. Petitioner was advised to continue physical therapy (PXI).

By June 15, 2010, Petitioner’s condition continued to improve. She only had pain in the left trapezius at that time. The pain did not radiate and she denied paresthesias, sensory loss, numbness, weakness, stiffness and radicular symptoms. She specifically denied any pain in her left shoulder and her left shoulder exam revealed full range of motion and no tenderness. Her diagnosis was trapezius strain and her restrictions remained the same. She was advised to continue physical therapy (PX I ).

On June 22, 2010, Petitioner reported that her symptoms were no better than when she was first injured indicating she felt that she took a step backwards. Her pain continued to be located over the left trapezius muscle. The left shoulder examination showed no deformity, no tenderness and full range of motion. The diagnosis remained trapezius strain and she was advised to continue physical therapy. Her restrictions were changed to 15 pounds lifting and no pushing/pulling over 30 pounds (PX1).

On June 28, 2010, Petitioner underwent a left shoulder MRI. The impression was focal supraspinatus tendinopathy and undersurface fraying at the humeral attachment. There was no large partial thickness or discrete full thickness rotator cuff tear. Also noted was minimal subacromial/subdeltoid bursitis and mild thickening of the coracoacromial ligament. (PX2).

Petitioner was referred to orthopedic surgeon, Dr. who saw Petitioner on June 30, 2010. Petitioner reported that she injured her left shoulder and neck while throwing bags. Dr. diagnosed left shoulder impingement and a cervical strain. Dr. recommended Petitioner continue with restrictions and if her symptoms did not improve, he would consider a cervical MR1. The doctor also injected the left shoulder with cortisone on that date. (PX 1)

Petitioner returned to Dr. on July 7, 2010. The doctor noted Petitioner had mild improvement with the cortisone injection. Dr. provided that “[she] really did not have improvement of her symptoms even with the cortisone and lidocaine injection into the subacromial space, which would indicate that she may have pathology elsewhere.” The doctor was concerned about cervical radiculopathy. Dr. ‘s impression was possible cervical radiculopathy and left shoulder impingement. A cervical MRI was prescribed and her restrictions remained the same. (PX 1)

Petitioner underwent the cervical MRI on July 8, 2010. The radiologist’s impression was there a moderate right paracentral disc protrusion at C5-6 which indents the ventral aspect of the spinal cord and resulting in mild spinal stenosis. (PX 1)

On July 14, 2010, Dr. noted the cervical MRI demonstrated cervical disk herniation. He diagnosed cervical radiculopathy and referred Petitioner to pain specialist for epidural steroid injection. Her restrictions were continued. (PX 1 )

On August 13, 2010 Petitioner presented to Dr. at Petitioner provided a consistent recitation of accident. She complained of pain in the left side of her neck into the upper trapezius and into the shoulder. She also reported occasional shocking discomfort that radiates down to the forearm. Dr. diagnosed symptomatic discogenic pain of the cervical spine. She was place on prednisone and Neurontin. She was advised to again participate in physical therapy and to remain off work. (PX2)

On August 27, 2010, Dr. noted Petitioner had more discomfort into the left upper trapezius. She did not have interscapular pain or scapular winging. Petitioner had no shoulder impingement signs and had full range of motion of both shoulders. Dr. assessed symptomatic discogenic neck pain. She offered to send Petitioner to a pain clinic for a cervical epidural injection. Petitioner decided against the injection and instead preferred to continue with physical therapy (PX2)

On September 17, 2010, Dr. noted Petitioner was not improving despite being compliant with treatment. Dr. diagnosed her with left cervical radiculitis without neurological deficit. She referred Petitioner to Dr. , a neurosurgeon, (PX2)

Petitioner presented to Dr. at on September 22, 2010. Petitioner reported immediate onset of shoulder pain following the June 2010 incident. Petitioner also reported that she had neck pain but same was not her predominant symptom at that time. After an examination, Dr. recommended an epidural steroid injection at C5-6 on the left and kept her off work at that time. (PX2)

Petitioner returned to Dr. on October 1, 2010 with continued complaints of left upper trapezius and posterior neck pain. Petitioner told Dr. that her left shoulder pain had returned specifically in the deltoid area. Dr. believed that her presentation was now more suggestive of a shoulder injury. Dr. referred Petitioner back to physical therapy for rotator cuff and scapular stabilizers. Petitioner was also prescribed Norco and kept on light duty. Dr. advised Petitioner to keep the epidural appointment but also to begin specific rotator cuff and scapular exercises (PX2).

At Respondent’s request, Petitioner was seen for an independent medical evaluation with Dr. on October 27, 2010. Dr. noted Petitioner reported an acute onset of left-sided neck and shoulder pain which subsequently developed into pain and paresthesias in the C5 distribution and paresthesias that radiated to the dorsum of the hand and all fingers on the left side only. Petitioner also relayed that her pains were constant and slowly getting worse. After reviewing medical records and performing an examination, Dr. opined that a result of the June 2010 incident, Petitioner suffered a left trapezius sprain. Relying on ‘s records he felt the sprain resolved within at 1-2 weeks. He felt that her symptoms on the dorsum of all of her fingers were not consistent with cervical radiculitis noting the cervical MRI was positive on the right side. Dr. wrote, [h]er symptoms are far more severe than can be substantiate on an objective basis. Her objective examination documents some mild tenderness consistent with a cervical spine sprain. However, her symptoms on the dorsum of all fingers are non-physiologic. Her shoulder examination is minimally abnormal and cannot he explained on any intrinsic shoulder pathology. The lack of response to subacromial cortisone injection proves that whatever inflammatory process may or may not be present on the MRI, is not causing her symptoms and certainly cannot be related to the accident in question…” (RX1).

Petitioner testified that prescribed injections were not approved by Respondent.

On November 16, 2010 Petitioner came under the care of Dr. The doctor notes indicate Petitioner presented for left shoulder and neck pain and that her symptoms were secondary to an injury at work. On examination Petitioner had positive impingement sign, specifically with internal rotation. She had a positive Spurling sign and an examination of the biceps revealed positive O’Brien’s for SLAP lesion Examination of the levator scapulae revealed tenderness to palpation at the supermedial aspect of the scapula. Dr. assessed shoulder pain, neck pain, and a SLAP lesion. Dr. believed that surgery was appropriate at that time. (PX3)

On December 1, 2010, a left shoulder MR1 with arthrogram was performed. The radiologist felt the images was highly suggestive of an anteroinferior labral tear and/or anteroinferior glenohumeral ligament glenoid attachment injury. A repeat arthrogram was recommended since the dye was not completely injected at the time of the original exam. The repeat arthrogram was never performed. (PX3)

Petitioner followed-up with Dr. on December 8, 2010. Dr. noted that although the MRI/arthrogram demonstrated a concern for possible labral pathology, nothing was definite. Dr. injected the left subacromial space and diagnosed shoulder pain, neck pain SLAP lesion, cervical radiculopathy and impingement. He noted that if Petitioner did not have any relief from the injection, arthroscopic intervention would be considered. (PX3).

On December 22, 2010, Dr noted that Petitioner experienced minimal improvement with the injection. He prescribed arthroscopic surgery in the form of a SLAP repair. The doctor also noted Petitioner demonstrates some cervical cross-over but feels she requires surgery. (PX 3)

Dr authored a second report dated March 4, 2011. He had the opportunity to review the updated records from Dr. including the arthrogram report. Dr. noted that because the subacromial injections did not provide relief, the clinical findings of impingement were a false-positive. He wrote that a truly positive impingement sign would include relief of pain with injection of the subacromial space. Regarding the SLAP lesion, Dr. noted that while the O’Brien’s test is the best test for that lesion, it is not 100% accurate. He stated that for the test to be truly positive for a SLAP lesion, the exam needs to be negative in supination and positive in pronation. Dr. noted the left shoulder MRI/arthrogram revealed that it was completely normal in the area of the attachment to the biceps tendon. He noted that while there was some abnormality, it was obscured by artifact. He also added that such an abnormality could not have been caused by the accident in question. Dr. believed there was insufficient objective evidence on the MRI to support the diagnosis of an SLAP lesion. He further added that the mechanism of lifting a suitcase onto a belt would not forward flex or abduct the arm even to eye level and that said mechanism of injury would be virtually impossible to have caused shoulder subluxation. (RX2)

Dr. noted that regardless of any relationship, there was completely insufficient objective evidence to justify left shoulder surgical intervention. Dr. wrote, “[i]n my opinion, having failed 2 subacromial injections, the only way I would agree that shoulder arthrocopy is justified is if an inta-articular injection. confirmed by arthrogram or ultrasound, eliminated her pain. lf, such an injection is performed and eliminates her pain for the duration of the local anesthetic, then I would agree that there is inta-aricular pathology which is simply not being confirmed by MRI. However…in the absence of such confirmation…LEFT shoulder arthroscopic surgery is contraindicated because it may very well aggravate her chronic pain condition but has completely insufficient evidence to support its use.” (RX 2)

Dr. opined that Petitioner’s current cervical complaints were not related to the original accident, Dr. reiterated that Petitioner suffered an un-complicated cervical spine/trapezius strain. He added that there is little if any objective evidence of any organic pathology to support her current diagnosis of chronic pain syndrome. Dr. reiterated his belief that based on the mechanism of injury and medical records Petitioner had a cervical sprain that could be reasonably attributed to the accident. He noted however that based on the medical records, it resolved within 1 or 2 weeks. (R2).

Petitioner testified that she is left hand dominant and had no left shoulder injuries prior to this incident. She is currently in constant pain and has trouble sleeping. She rates her pain at 8 to 9/10 and takes prescribed medication for pain. Petitioner expressed her desire to undergo the procedure prescribed by Dr.

IN REGARD TO (F), WHETHER THE PETITIONER’S PRESENT CONDITION OF ILL-BEING IS CAUSALLY RELATED TO HER WORK INJURY, THE ARBITRATOR FINDS AS FOLLOWS:

Petitioner was injured on June 7, 2010 as she was lifting a 45 pound luggage bag off a scale and throwing it off the belt. Petitioner reported her injury and Respondent sent her to Medical Center where she treated with Drs. . Initially she was diagnosed with a left shoulder strain and prescribed physical therapy. During the course of treatment Petitioner reported continuing symptoms. A MRI of the left shoulder noted focal supraspinatus tendinopathy and undersurface fraying at the humeral attachment. Also noted was subacromial/subdeltoid bursitis and mild thickening of the coracoacromial ligament. Petitioner was referred to ‘s orthopedic surgeon, Dr. who diagnosed left shoulder impingement and a cervical strain. Under Dr. ‘s care, Petitioner underwent cortisone and lidocaine injections which only provided mild improvement. As a result, the doctor was concerned about cervical radiculopathy. A cervical MRI was ordered which when performed demonstrated C5-6 cervical disk herniation. Dr. referred Petitioner to pain specialist, Dr. . Dr. diagnosed symptomatic discogenic pain of the cervical spine and recommended cervical epidural injections. Petitioner opted not to undergo the injections but instead preferred to continue with physical therapy. Despite being compliant with treatment recommendations, Petitioner was not experiencing significant improvement. As a result, Dr. referred Petitioner to Dr. , a neurosurgeon, of who also recommended epidural steroid injection. Petitioner returned to Dr. with continual complaints of left upper trapezius and posterior neck pain. Dr. believed that her presentation was more suggestive of a shoulder injury. Dr. referred Petitioner back to physical therapy for rotator cuff and scapular stabilizers. Dr. – also advised Petitioner to try the epidural injection. The injections were not approved by Respondent.

Petitioner subsequently sought the care of Dr. . The doctor notes indicate Petitioner presented for left shoulder and neck pain and that her symptoms were secondary to an injury at work. After an examination, Dr. assessed shoulder pain, neck pain, and a SLAP lesion. Dr. believed surgery was appropriate at that time and ordered a left shoulder MR1 with arthrogram. The radiologist felt the images were highly suggestive of an anteroinferior labral tear and/or anteroinferior glenohumeral ligament glenoid attachment injury. However, a repeat arthrograrn was recommended since the dye was not completely injected at the time of the original exam. The repeat arthrogram was never performed. Dr. later injected the left subacromial space. Dr. noted Petitioner experienced minimal improvement with the injection and prescribed arthroscopic surgery in the form of a SLAP repair. The doctor also noted Petitioner demonstrates some cervical cross-over but feels she requires surgery.

Based on the evidence demonstrating that Petitioner had no history of prior shoulder pain, followed by a specific mechanism of injury, which was followed by an immediate consistent course of medical treatment and ongoing symptoms from the date of injury to the present time, the Arbitrator finds Petitioner’s present condition of ill-being is causally related to the June 7, 2010 work injury.

The Arbitrator notes that although Dr. is of the opinion that there is insufficient objective evidence to support that Petitioner’s current shoulder and cervical complaints are causally related to the accident sustained in June 2010, there is an inference that Petitioner may in fact have some pathology. As Dr. wrote, “[i]n my opinion, having failed 2 subacromial injections, the only way I would agree that shoulder arthrocopy is justified is if an inta-articular injection, confirmed by arthrogram or ultrasound, eliminated her pain. lf, such an injection is performed and eliminates her pain for the duration of the local anesthetic, then I would agree there is inta-aricular pathology which is simply not being confirmed by MRI…”

WITH REGARD TO ITEM (J), WERE THE MEDICAL SERVICES PROVIDED PETITIONER REASONABLE AND NECESSARY AND HAS RESPONDENT PAID ALL APPROPRIATE CHARGES, AND K. WITH REGARD TO ITEM (K), WHETHER THE PETITIONER IS ENTITLED TO ANY PROSPECTIVE MEDICAL CARE, THE ARBITRATOR FINDS AS FOLLOWS:

Having reconciled that Petitioner’s current condition of ill-being is causally related to the accident sustained on June 7, 2010, the Arbitrator finds that the medical services provided to Petitioner were reasonable and necessary. She has undergone courses of physical therapy, diagnostic testing, office appointments, which culminates with a prescription for surgical intervention. The Arbitrator finds that Respondent is liable for all reasonable and necessary medical bills incurred as a result of the Petitioner’s June 7, 2010 work injury. Respondent shall receive credit for any and all medical bills that have been paid to date.

The Arbitrator further finds that Respondent shall authorize the prospective medical treatment as recommended by Dr.

WITH REGARD TO ITEM (L), WHAT TEMPOARY TOTAL DISABILITY BENEFITS ARE IN DISPUTE, THE ARBITRATOR RENDERS THE FOLLOWING FINDINGS OF FACT AND CONCLUSIONS OF LAW:

Petitioner was temporarily and totally disabled from June 7, 2010 to the present and is awarded 40 and 2/7ths weeks of temporary total disability benefits. Petitioner’s medical records from and Dr. indicate that Petitioner was initially put on restrictions on June 7, 2010 which were not accommodated and then taken off of work entirely on August 27, 2010 to the present.

Respondent shall be given a credit for TTD benefits that have been paid to date.