BEFORE THE ARKANSAS WORKERS COMPENSATION COMMISSION OPINION FILED ON MAY 2, 2017

Transcription

1 BEFORE THE ARKANSAS WORKERS COMPENSATION COMMISSION CLAIM NO. G LENA CAIN, EMPLOYEE VISITING ANGELS OF ARKANSAS, EMPLOYER MEADOWBROOK INSURANCE GROUP, INSURANCE CARRIER CLAIMANT RESPONDENT RESPONDENT OPINION FILED ON MAY 2, 2017 A hearing was held before ADMINISTRATIVE LAW JUDGE CHANDRA L. BLACK, in Little Rock, Pulaski County, Arkansas. The claimant was represented by The Honorable Scott Hunter, Attorney at Law, Jonesboro, Arkansas. Respondents were represented by The Honorable Jason Lee, Attorney at Law, Little Rock, Arkansas. STATEMENT OF THE CASE A hearing was held in the above-styled claim on March 29, 2017, in Little Rock, Arkansas. A Pre-hearing Telephone Conference was conducted in this case on January 25, A Pre-hearing Order was entered in this claim on that same date. This Pre-hearing Order set forth the stipulations offered by the parties, the issues to be litigated, and their respective contentions. The following stipulations were submitted by the parties, either pursuant to the Pre-hearing Order, or at the start of the hearing. The following stipulations are hereby accepted: 1

2 1. The Arkansas Workers Compensation Commission has jurisdiction of the within claim. 2. The employee-employer-insurance carrier relationship existed at all relevant times, including on December 18, The claimant s right shoulder and possibly other bodily parts were injured on December 18, benefits. 4. The respondents have paid some indemnity and medical 5. This claim for additional benefits has now been controverted in its entirety. 6. All issues not litigated herein are reserved under the Arkansas Workers Compensation Act. By agreement of the parties, the sole issue to be litigated at the hearing was as follows: whether the claimant is entitled to additional reasonable and necessary medical for her compensable right shoulder injury, in the form of surgery, by Dr. Larry Nguyen. The claimant contends the following: See medical attached. Wage loss and re-hab will be considered after surgery, if authorized, and convalescence. The respondents contend the following: The Claimant suffered an injury to her right shoulder on December 18, Dr. Kirk Reynolds, an orthopedic surgeon in Little Rock, treated the claimant and diagnosed her with a full-thickness supraspinatus tendon tear and a Type II SLAP tear, both of which he surgically repaired. Claimant underwent post-operative physical therapy, but continued to complaint [sic] of pain and soreness. She subsequently underwent a second-opinion evaluation by Dr. 2

3 Nguyen on March 2, 2016, who opined that she may have suffered re-tear of her tendon and recommended another MRI of the shoulder to determine whether this had occurred. The Claimant had the recommended MRI and was seen again by Dr. Reynolds on March 25, Following a clinical evaluation and review of the MRI scan, Dr. Reynolds opined that her rotator cuff repair was in tact with no muscle belly atrophy, of the supraspinatus muscle. Nonetheless, Dr. Reynolds ordered an EMG/NVC study to evaluate whether the Claimant had suffered a denervation injury. Dr. Brent Sprinkle performed the EMG/NVC on May 11, 2016, which was essentially normal. On May 18, 2016, Dr. Reynolds released the Claimant to return to work at full, unrestricted duty. He assigned a 4-percent whole-person impairment rating, which the Respondents accepted and paid. Subsequently, the Claimant returned to Dr. Nguyen at her own expense. The Claimant contends that Dr. Nguyen recommends a right-shoulder arthroscopy. Claimant has petitioned the Commission for a Change of Physician to Dr. Nguyen. Respondents contend that the procedure is not reasonable or necessary based on the findings of Dr. Reynolds and the results of the March 2016 MRI and May 2016 EMG/NCV. The documentary evidence submitted in this case consists of the hearing transcript of March 29, 2017 and the documents contained therein. Also, the claimant filed a Claimant s Posttrial Brief, this has been blue-backed and made a part of the record. It has been marked as Commission s Exhibit No. 2. The following witnesses testified at the hearing: the claimant and Henry Cain. DISCUSSION At the time of the hearing, the claimant was fifty-seven years old. The claimant testified that her injury occurred as she was transporting a patient from the recliner to her wheelchair, and then to the bed. According to the claimant, the patient s leg must have given-out, and they both fell. According 3

4 to the claimant, she fell and hit her head, right shoulder and back. The claimant stated that she first saw a doctor about her injuries the next day. From there, the claimant was referred to a specialist, Dr. Kirk Reynolds. She verified that the workers comp agent, Brenda Williams, chose Dr. Reynolds for his initial full examination. The two of them had several conversations back and forth. According to the claimant, Dr. Reynolds gave her medications for her shoulder and told her to come back in about six weeks. The claimant did so. At that time, her shoulder was catching, for which he referred her to physical therapy treatment. They put her in therapy for six weeks, and applied ice and heat to her shoulder. The claimant testified that she was put in therapy again, which included pulley modalities, which she had to pull back and forth. This caused the claimant s right shoulder to swell. According to the claimant, Dr. Reynolds had no other treatment to offer her during her last visit in May of Next, the respondents sent the claimant for a second opinion, by Dr. Nguyen, an orthopedic surgeon, in Little Rock. The claimant testified that she likes Dr. Nguyen because he explained everything to her. According to the claimant, Dr. Nguyen gave her the options of physical therapy, injections, or 4

5 surgery. The claimant further testified that she told him that she did not want to do the injections or physical therapy. She verified that she was planning to have the surgery by Dr. Nguyen, but the operation was canceled by the respondent-insurance carrier. As a result, the claimant has continued to treat with Dr. Nguyen, in the form of pain medication. As of the date of the hearing, the claimant had not undergone the surgery. The claimant testified that her condition has worsened. As of the date of the hearing, the claimant had an aching-like pain, which was not there when she was released by Dr. Reynolds. She agreed that her pain has intensified after being released by Dr. Reynolds. When asked the severity of her pain, the claimant replied, Oh my God. It was terrible. Currently, the claimant has restrictions of no lifting over 20 to 25 pounds, no pulling and no overhead lifting. She denied that she is able to perform the type of work she performed at the time of her injury. The claimant testified that if she tries to lift a plate or cup, her right arm gives out, and the pain is still intensive. She further testified that she has problems raising her right arm. The claimant verified that she has performed physical labor all of her life. She admitted that she had an accident involving her back in 5

6 2013. The claimant denied ever being treated and/or examined for her right shoulder at UAMS. She denied ever having an injury to her right shoulder, despite being shown a report that states otherwise. However, the claimant later remembered having a pinched nerve and tingling in the right shoulder, for which she went to UAMS and was given medication. It appears that this visit was in She verified that Dr. Nguyen went what the procedure entailed. He told her that the procedure would take about an hour, and she would not have to stay in the hospital. The claimant admitted that she wants to have the surgery done so that she can feel better and return to the workforce. She verified that she has confidence in Dr. Nguyen and likes the way he attended to her. On cross-examination, the claimant admitted that she was involved in a motor vehicle accident in The claimant was shown a report of an emergency room visit to UAMS on January 17, 2012, wherein she complained of right shoulder pain since a motor vehicle accident in November. The claimant admitted that she was involved in a motor vehicle accident in However, the claimant denied that she continued to have problems with her right shoulder. She admitted that she suffers from migraines headaches, for which she takes Topamax. The claimant denied that she has been 6

7 taking medication for migraines since She did not recall going to UAMS due to migraine headaches on November 4, 2008, but did not disagree with the medical report. The claimant also did not recall complaining of headaches in August of The claimant admitted that she underwent an MRI and a nerve conduction test. She denied that she was aware that the nerve study came back negative. The claimant denied that she requested that Dr. Reynolds close out her workers comp claim. On redirect examination, the claimant denied having an accident to her right shoulder after being released by Dr. Reynolds. Henry Cain, the claimant s husband testified on behalf of his wife. They have been married for six years. Mr. Cain works at the Pine Bluff Arsenal. He has been employed by them for 14 years. He verified that the claimant s shoulder injury has changed her sleep habits. Mr. Cain testified now, that the claimant is always complaining about her shoulder. He agreed that her complaints have gotten progressively worse. Further review of the documentary medical evidence of record demonstrates that the claimant sought medical treatment from Dr. Kirk A. Reynolds, on July 24, 2015, due to right shoulder pain. In an Initial Evaluation Report, Dr. Reynolds wrote, in relevant part: MEDICAL DECISION MAKING X-RAY INTERPRETATION 7

8 3 views of the right anything to be per paper work is ligaments are dramatically improved with shoulder were obtained today and personally reviewed. Glenohumeral alignment and architecture is normal. There is moderate AC joint arthrosis. No glenhumeral arthritis. The humeral head is well centered in the glenoid without evidence of posterier subluxation or superior escape. Type III acromion. An MRI scan of the right shoulder dated 5/7/15 was personally reviewed today. There are some degenerative changes in the posterior labrum. She has a high-grade partial-thickness tear of the supraspinatus tendon with a focal full-thickness tear anteriorly. Significant acromioclavicular arthrosis. Subacromial impingement anatomy is identified. ASSESSMENT Right shoulder pain and persistent weakness associated with rotator cuff tear, posterior labral tear, biceps tendinitis and acromioclavicular arthrosis. This has failed nonoperative treatment including coriscosteroid injections and physical therapy. PLAN Given her failure to respond to nonoperative treatment my recommendation is for a right shoulder arthroscopy with planned rotator cuff repair, open subpectoral biceps tenodeses, distal clavicle excision and subacromial decompression. Risks and benefits of surgery, as well as, alternative treatment options were discussed at length. She is willing to accept the risks of surgery and wishes to proceed. Postoperative recovery and rehabilitation was outlined. We are going to schedule her for the above-noted right shoulder once approved by Worker s Compensation. She has not reached MMI. She remains on modified duty at work. Restrictions are no lifting, pushing or pulling with the right upper extremity. Dr. Reynolds authored a Radiology Report, on that same date. This report, reads in relevant part: An MRI scan of the right shoulder dated 5/7/15 was personally reviewed today. There are some degenerative changes in the posterior labrum. She has a high grade partial-thickness tear of the supraspinatus tendon with a 8

9 full focal-thickness tear anteriorly. Significant acromioclavicular arthrosis. Subacromial impingement anatomy is identified. Think we need to get a new MRI scan to get a better idea of exactly what s going on with her rotator cuff repair. If this is normal then the next step would be an FCE. On August 18, 2015, Dr. Reynolds wrote the following in an Operative Report: PREOPERATIVE DIAGNOSIS 1. Right shoulder full-thickness supraspinatus tendon tear. 2. Right shoulder biceps tendinitis. 3. Right shoulder acromioclavicular arthrosis. 4. Right shoulder subacromial impingement syndrome. POSTOPERATIVE DIAGNOSIS 1. Right shoulder full-thickness supraspinatus tendon tear. 2. Right shoulder Type II SLAP tear. 3. Right shoulder biceps tendinitis. 4. Right shoulder acromioclavicular arthrosis. 5. Right shoulder subacromial impingement syndrome. PROCEDURE PERFORMED 1. Right shoulder diagnostic arthroscopy with arthroscopicassisted rotator cuff repair. 2. Right shoulder open subpectoral biceps tenodesis. 3. Right shoulder arthroscopic distal clavicle excision. 4. Right shoulder arthroscopic limited glenhumeral debridement. 5. Right shoulder arthroscopic subacromial decompression with partial acromioplasty. Dr. Reynolds saw the claimant for a follow-up visit on August 28, 2015: ASSESSMENT Right shoulder pain and persistent weakness associated with rotator cuff tear, posterior labral tear, biceps tendinitis and acromioclavicular arthrosis. This has failed nonoperative treatment including corticosteroid injections and physical therapy. PLAN Given her failure to respond to nonoperative treatment my 9

10 recommendation is for a right shoulder arthroscopy with planned rotator cuff repair, open subpectoral biceps tenodesis, distal clavicle excision and subacromial decompression. Risks and benefits of surgery, as well as, alternative treatment options were discussed at length. She is willing to accept the risks of surgery and wishes to proceed. Postoperative recovery and rehabilitation was outlined. We are going to schedule her for the above-noted right shoulder surgery once approved by Worker s[sic] Compensation. The claimant returned to Dr. Reynolds on September 25, 2015, for her six(6) weeks postoperative evaluation. He reported that the claimant was doing well and could discontinue the sling. Dr. Reynolds recommended that the claimant continue in physical therapy per protocol. However, he opined that the claimant had not reached MMI. Per an Office Visit note dated November 6, 2015, Dr. Reynolds noted that the claimant had poor progress with right shoulder arthroscopy. He stated that the claimant was developing adhesive capsulitis of the right shoulder. As a result, Dr. Reynolds recommended that the claimant undergo a glenohumeral cortical steroid injection of the right shoulder, to help alleviate some of her pain. He also recommended that they change therapy locations, in an effort to get more skilled hands-on physical therapy. An Office Visit Note was authored by Dr. Reynolds on December 18, Dr. Reynolds wrote, in relevant part: HISTORY OF PRESENT ILLNESS: Ms. Cain returns to clinic today for routine followup of her 10

11 right shoulder. She had an arthroscopic rotator cuff repair, distal clavicle excision, and open biceps tenodesis on August 18, This was associated with a work injury. She has struggled postoperatively with adhesive capsulitis and persistent pain. When I last saw her six weeks ago, I recommended an intra-articular corticosteroid injection under ultrasound guidance. This was finally approved by her worker s comp insurance, and she had this done yesterday. Today, she is having a little more pain in the shoulder secondary to the injection. She feels that she is getting better with physical therapy. * * * IMPRESSION: Persistent stiffness and pain in the right shoulder four months status post above-noted arthroscopy. She just had an injection yesterday. PLAN: 1. She will continue physical therapy. 2. I explained to her that it may take several days for the soreness to wear off after the steroid injection. 3. We refilled her Vicoprofen today. 4. She remains on modified duty at work. 5. She has not reached MMI. 6. Return to clinic I six weeks for motion check. On March 2, 2016, Dr. Larry Nguyen saw the claimant for an independent evaluation. He wrote, in relevant part: IMPRESSION: Right rotator cuff syndrome status post arthroscopic repair of a SLAP tear, biceps tenodesis, acromioplasty and distal clavicle resection (M75.101) with adhesive capsulitis (M75.101). PLAN: 1. It looks like the patient was seen and appropriately treated with Dr. Reynolds. Unfortunately, this extensive surgery with arthroscopic rotator cuff repair, biceps tenodesis, SLAP repair, distal clavicle resection and acromioplasty requires extensive physical therapy postoperatively to avoid postoperative stiffness and weakness with guarded prognosis to returning to her previous full-duty manual lifting activities. 11

12 2. At this point she has developed some postoperative arthrofibrosis, right rotator cuff syndrome and adhesive capsulitis and maybe even potential re-tear, as the arthroscopic repairs work well on young athletes but in the older individuals the tendon may or may not heal well and there is some tendency for re-tearing or re-rupture. She is six months postop and has maximized physical therapy. We could consider a manipulation and steroid injection to try to break up the scar tissue and get her better motion, which would have guarded results for improved pain. Really at six months postop a better option may be to repeat the MRI scan of her right shoulder to evaluate for re-tear of the rotator cuff and I would recommend if revision surgery is indicated to proceed with an outpatient surgery, general anesthesia 1-1/2 hours breach chair position, for a right shoulder arthroscopic debridement with an open rotator cuff repair acromioplasty using Biomet JuggerKnot anchors to fully visualize and repair any re-tear that may be present. 3. The patient does not appear to be malingering. She is relatively young, active and healthy and would like to return to work. I believe it is in her best interest to proceed with further interventions as her current painful shoulder is severe and debilitating and not amenable to full activities of daily living. We will try to get Workers Compensation to approve another MRI scan of her right shoulder to evaluate the repair and call her back with the test results. 4. I would be happy to assume care of this patient if she desires. Otherwise, she is in capable hands with Dr. Kirk Reynolds. Dr. Reynolds saw the claimant for a follow-up visit on March 25, He wrote, in pertinent part: ASSESSMENT Persistent right shoulder pain and weakness 7 months status post arthroscopic rotator cuff repair, biceps tenodesis, distal clavicle excision, glenohumeral debridement and subacromial decompression. PLAN I explained to Mrs. Cain in clinic today that I am really at a loss as to the exact nature of her persistent pain and weakness. I am a little bit suspicious given the fact that her passive motion is well preserved. Her rotator cuff repair is intact based upon repeat MRI scan and there is no muscle belly atrophy of the supraspinatus muscle which would 12

13 indicate disuse atrophy. This makes me a little suspicious that she is actually using the arm much more that she indicates on clinical exam. Regardless, given her subjective complaints I think we need to investigate this further. My recommendation would be for an EMG/NCV study of the right upper extremity to evaluate for any denervation injury to the rotator cuff. In the absence of abnormality here I would recommend a second opinion with a shoulder specialist Dr. Nguyen, whom she saw earlier, is actually a foot and ankle specialist I would recommend requesting a second opinion from my partner Dr. Chuck Pearce, my partner Dr. Michael Hussey or a shoulder specialist elsewhere. I would recommend Dr. Adam Smitherman at OrthoArkansas or Dr. Ahmadi at UAMS as potential second opinions outside of our group. An MRI of the claimant s right shoulder was performed on that same date, with the following impression: 1. Postoperative changes in the AC joint with subacromial decompression and supraspiratus tendon to bone repair. No repeat tear of the tendon. 2. Status biceps tenodesis. 3. Early degenerative change across the glenohumeral joint with physiologic amount of joint fluid. 4. Small amount of fluid in the subacromial subdeltoid bursa probably due to mild bursitis. On May 18, 2016, the claimant saw Dr. Reynolds for follow up of her right shoulder: Plan Per her request Mrs. Cain will be placed at Maximum Medical Improvement. She may return to full, unrestricted duty. According to the AMA Guidelines to the Evaluation of Permanent Impairment, Fourth Edition Mrs. Cain has two areas of partial, permanent impairment. The first area of impairment is related to her distal clavicle excision. Utilizing Table 27 on page 61 she is assigned a 4% permanent impairment. The second area of impairment is related to her rotator cuff weakness. Utilizing Tables 12 and 15 on pages 49 and 54 respectively she is assigned a 2% impairment for weakness. The Combined Values Chart on page 322 signs a total partial, permanent impairment of the right shoulder at 13

14 6%. This equates to a 4% partial permanent impairment of the whole person according to Table 3 on page 20. Dr. Nguyen saw the claimant for a follow-up on July 22, He wrote, in relevant part: 16, 2016: IMPRESSION Right rotator cuff syndrome status post arthroscopic repair of SLAP tear biceps tenodesis, acromioplasty, and distal clavicle resection (M75.101) with adhesive capsulitis. Dr. Nguyen wrote the following in an addendum dated August I reviewed her MRI scan from March 25, It shows postoperative changes with severe attenuation of the rotator cuff with moderate edema. It has become so severe and debilitating that she wishes to go ahead and proceed with surgical interventions as stated. A Change of Physician Order was entered on November 29, 2016 by the Commission for the claimant to change from treating with Dr. Kirk Reynolds to treat with Dr. Larry Nguyen. On March 15, 2017, Dr. Nguyen wrote the following in an Office Visit Note: IMPRESSION Right rotator cuff syndrome (M75.101) status post SLAP repair, biceps tenodesis, acromioplasty and distal clavicle resection with adhesive capsulitis (M75.101). PLAN 1. At this point she is quite stiff and weak. The most recent MRI scan shows postoperative change, no frank tear. I discussed this with her that she can continue treating this with injections and physical therapy exercises. 2. However, failing these nonoperative measures and having chronic pain, the only other option would be a revision surgery, somewhat exploratory diagnostic, to include an outpatient surgery, general anesthesia beach chair position 1-1/2 hours, for a right shoulder arthroscopic debridement 14

15 with possible revision open rotator cuff repair acromioplasty using Biomet JuggerKnot anchors to fully visualize and repair any repeat tear that may be present, as the MRI scans are not always 100 percent. 3. She will see UAMS for a second opinion. 4. I will refill her hydrocodone one last time. 5. Apparently her attorney asked for a rating. Workers Compensation did not cover repeat surgery so we will have her released from our care having reached maximum medical improvement as of today with permanent restrictions of not lifting more than pounds and limited overhead activities with a partial impairment rating of 20% to the shoulder, 10% upper extremity and 6% whole person based on the AMA Guidelines Fourth Edition, Chapter 3, pages Figures 38, 41 and 44. Feel free to contact my office for any further questions or concerns. All stated opinions above are with reasonable degree of medical certainty. On March 22, 2017, the respondents attorney wrote a letter to Dr. Reynolds regarding the treatment recommended by Dr. Nguyen. Respondents counsel asked several questions of Dr. Reynolds with respect to Dr. Nguyen s recommendation for right shoulder arthroscopic debridement with open rotator cuff repair acromioplasty using Biomet JuggerKnot anchors to fully visualize any retear that may be present. In a letter dated March 22, 2017, Dr. Reynolds wrote the following: I have reviewed your letter dated March 22, 2017 regarding patient Lena Cain. Her date of injury was December 18, Claim number is G On August 18, 2015 I performed a right shoulder arthroscopy with repair of her supraspinatus tendon tear, an open subpectoral biceps tenodesis, a distal clavicle excision, a limited glenohumeral debridement and a subacromial decompression with partial acromioplasty. She had a very difficult postoperative course with persistent pain and stiffness in her shoulder. An IME was performed by Dr. Larry Nguyen and I saw her subsequently on March 25,

16 At that point I recommended a second opinion from one of the other shoulder specialist here in central Arkansas. I also recommended an EMG/NCV study to evaluate any denervation injury to her rotator cuff. This EMG/NCV study was performed by Dr. Brent Sprinkle on May 11, It was normal. When I re-evaluated her on May 18, 2016 she stated that she wanted no additional treatment. Thus, she was released at Maximum Medical Improvement and assigned a 6% impairment of the right shoulder and a 4% partial impairment of the whole person. Since being released, according to your letter, she requested a change of physician. This request was granted by the AWCC. She is currently under the care of Dr. Larry Nguyen. According to his most recent note dated July 22, 2016 he has recommended a repeat arthroscopy with open revision rotator cuff repair. His review of her MRI scan dated March 25, 2016 is as follows, It shows postoperative changes with severe arthrosis of the AC joint and attenuation of the rotator cuff with moderate edema. Questions asked of me and answered are as follows: 1. Do you agree with Dr. Nguyen s interpretation of the March 25, 2016 right shoulder MRI? Why or Why not? I disagree with Dr. Nguyen s interpretation. This MRI scan shows postsurgical changes in the acromioclavicular joint consistent with her history of a prior distal clavicle excision. Also, postsurgical changes are seen in the supraspinatus tendon consistent with her repair. Abnormal signal was seen in the humeral head around the suture anchors. There is abnormal, postsurgical signal in the subacromial bursa. There is no abnormal signal within the rotator cuff tendon. Of note, the interpreting radiologist described postoperative changes in the AC joint with subacromial decompression and supraspinatus tendon to bone repair. No repeat tear of the tendon. 2. Do you agree with Dr. Nguyen surgical recommendation is described in his July 22, 2016 report? Why or Why not? It is my professional medical opinion that no revision rotator cuff repair is indicated as there is no recurrent tear on the MRI scan from March 25, It is not beyond possibility that she re-tore her rotator cuff in the past 12 months: however, this would require a repeat MRI scan to diagnose. Also, she has already had an acromioplasty and I do not agree with a revision acromioplasty since there is no recurrent subacromial spur. As a sports medicine and 16

17 shoulder specialist I would perform an arthroscopic rotator cuff repair and do not believe that an open repair offers any advantages. However, Dr. Nguyen may feel more comfortable with open surgery. Regardless based upon review of these records I do not see a medical indication for repeat surgical treatment. These statement are provided within a reasonable degree of medical certainty. Please do not hesitate to contact my office with any questions, concerns or for further clarification. ADJUDICATION Reasonable and Necessary Medical Treatment An employer shall promptly provide for an injured employee such medical treatment as may be reasonably necessary in connection with the injury received by the employee. Ark. Code Ann (a). The claimant bears the burden of proving that she is entitled to additional medical treatment. Dalton v. Allen Eng'g Co., 66 Ark. App. 201, 989 S.W. 2d 543 (1999). On the basis of the record as a whole, and after reviewing the evidence in this case impartially, without giving the benefit of the doubt to either party, I find that the claimant has sustained her burden of proving by a preponderance of the evidence that she is entitled to additional reasonable and necessary medical treatment, in the form of surgery, by Dr. Nguyen, for her admittedly right shoulder injury of December 18, Here, the claimant sustained a fall on December 18, 2014, while attempting to transfer a patient from the recliner to the 17

18 bed. It appears that the claimant reported her injury and was seen by the company doctor, the next day. She underwent initial evaluation by Dr. Reynolds, on July 24, 2015, due to right shoulder pain. At that time, Dr. Reynolds assessed her with: Right shoulder pain and persistent weakness associated with rotator cuff tear, posterior labral tear, biceps tendinitis and acromioclavicular arthrosis. This has failed nonoperative treatment including corticosteroid injections and physical therapy. On August 18, 2015, Dr. Reynolds performed the following surgical procedures, on the claimant s right shoulder: 1. Right shoulder diagnostic arthroscopy with arthroscopicassisted rotator cuff repair. 2. Right shoulder open subpectoral biceps tenodesis. 3. Right shoulder arthroscopic distal clavicle excision. 4. Right shoulder arthroscopic limited glenhumeral debridement. 5. Right shoulder arthroscopic subacromial decompression with partial acromioplasty. Following the above surgery modalities, the claimant underwent several sessions of physical therapy. However, the claimant had poor progress with the surgery. The medical records and the claimant s testimony show that she continued with chronic right shoulder pain, persistent weakness, and other difficulties of her shoulder despite additional conservative treatment. Specifically, on November 6, 2015, Dr. Reynolds opined that the claimant was developing adhesive capsulitis of the right shoulder. As a result, Dr. Reynolds recommended that the 18

19 claimant undergo a cortical steroid injection of the right shoulder to help alleviate some of her pain and other symptomatology. At that time, Dr. Reynolds further recommended that they change the location/provider of her physical therapy, in an attempt to obtain more skilled hands-on therapy. However, the claimant continued with ongoing complaints of severe pain and other related symptomatology of the right shoulder. As a result, on March 2, 2016, the claimant underwent an independent medical evaluation by Dr. Nguyen, at the request of the respondent-insurance carrier. Dr. Nguyen opined that the claimant did not appear to be malingering. In a Office Note, from that same date, Dr. Nguyen opined, in relevant part: At this point she has developed some postoperative arthrofibrosis, right rotator cuff syndrome and adhesive capsulitis and maybe even potential re-tear, as the arthroscopic repairs work well on young athletes but in the older individuals the tendon may or may not heal well and there is some tendency for re-tearing or re-rupture. She is six months postop and has maximized physical therapy. We could consider a manipulation and steroid injection to try to break up the scar tissue and get her better motion, which would have guarded results for improved pain. Really at six months postop a better option may be to repeat the MRI scan of her right shoulder to evaluate for re-tear of the rotator cuff and I would recommend if revision surgery is indicated to proceed with an outpatient surgery... An MRI of the claimant s right shoulder was performed on March 25, This diagnostic test showed, in relevant part, Early degenerative changes across the glenohumeral joint with physiologic amount of joint fluid, but no repeat tear of the tendon. The claimant underwent an EMG/NVC on May 11, 2016, by 19

20 Dr. Brent Sprinkle. Of note, this study was not made a part of the record. On May 18, 2016, the claimant returned to Dr. Reynolds and he reported that the claimant requested that he place her at maximum medical improvement. The claimant denied having done so. Nevertheless, Dr. Reynolds placed the claimant at MMI, and returned her to full duty work. He also assessed the claimant with a permanent partial impairment rating of 6% to the right shoulder, and a 4% partial permanent impairment of the whole person. On November 29, 2016, the claimant obtained a Change of Physician Order to change from Dr. Kirk Reynolds to Dr. Larry Nguyen. The claimant continued with complaints of worsening shoulder pain and related symptoms while under the conservative care of Dr. Nguyen. Ultimately, on March 17, 2017, Dr. Nguyen recommended that the claimant undergo possible revision surgery, somewhat exploratory diagnostic with arthroscopic debridement. He also discussed with the claimant, other options of physical therapy and injections. The claimant testified that she was scheduled for surgery but was told it had been cancelled by the respondents. Her testimony demonstrates that she is comfortable with the explanation and care provided to her under her treating 20

21 physician, Dr. Nguyen. As such, she is requesting that she be allowed to undergo surgery by Dr. Nguyen. After having observed the claimant s demeanor at the hearing, and when comparing her testimony with the documentary evidence, I find that the claimant was a credible witness. However, I am persuaded that the claimant was less than forthcoming about the prior problem with her right shoulder in January of Nonetheless, there is no evidence whatsoever, demonstrating that the claimant had any ongoing problems with her right shoulder. Prior to her injury of December of 2014, the claimant was able to perform her job duties without any difficulties relating to her shoulder. There is no evidence that she missed any work due to right shoulder problems. However, the claimant s testimony and the documentary evidence demonstrate that despite surgery, several physical therapy sessions, and an extensive medication regimen, she has continued to develop significant pain and related symptomatology of the right shoulder. Specifically, since this time, the claimant has experienced significant loss of use of her right shoulder. Hence, the claimant is unable to even lift a plate or cup without having her arm give-out on her. The claimant denied any subsequent falls or injuries to her right shoulder. As previously referenced, the claimant expressed a willingness to undergo a second surgery to her shoulder, with of 21

22 course, her treating physician. Her testimony demonstrates that she wishes to have her shoulder fixed so that she can return to the workforce. Given that fact that prior treatment modalities has fail to resolve the claimant s right shoulder symptoms, I am persuaded that her best course of action in this instance would be surgical intervention. To summarize, in light of the persistent nature of the claimant s symptoms since her compensable fall in December of 2014, despite several sessions of physical therapy treatment; the subsequent objective finding on the MRI of severe attenuation of the cuff with moderate edema (which are not required to be established for additional medical treatment), there being no subsequent accident, the lack of symptoms prior to her accident and based on the expert opinion of her treating physician, Dr. Nguyen, I find that the claimant proved by the preponderance of the evidence that additional medical treatment is reasonable and necessary for her admittedly compensable right shoulder injury, under the care of her treating physician. While I realize that Dr. Reynolds opined that surgery is not warranted, minimal weight has been attached to his opinion considering the objective findings of the MRI, the debilitating nature of the claimant s symptoms, the expert opinion of the claimant s treating physician, that Dr. Nguyen has opined that the MRI scans are not always 100 percent in visualizing repeat 22

23 tear, and because the claimant has failed conservative treatment and surgery. I also think it is noteworthy that Dr. Nguyen opined that this surgery would somewhat be exploratory diagnostic and a possible revision open rotator cuff repair. Of note, Dr. Reynolds has not physically examined the claimant since May of The respondents are therefore liable for additional medical treatment in this matter for the claimant s right shoulder condition. FINDINGS OF FACT AND CONCLUSIONS OF LAW On the basis of the record as a whole, I make the following findings of fact and conclusions of law in accordance with Ark. Code Ann The Arkansas Workers Compensation Commission has jurisdiction of the within claim. 2. The employee-employer-insurance carrier relationship existed at all relevant times, including December 18, I hereby accept the above mentioned proposed stipulations as fact. 4. The claimant proved that the recommended medical treatment for her right shoulder injury, in the form of surgery, by Dr. Nguyen, is reasonable and necessary for the injury received by her on December 18, All issues not litigated herein are reserved under the Arkansas Workers Compensation Act. AWARD 23

24 The respondents are directed to medical pay benefits in accordance with the findings of fact set forth herein this Opinion. All issues not addressed herein are expressly reserved under the Act. IT IS SO ORDERED. CB/kw CHANDRA L. BLACK Administrative Law Judge 24