[7] 5-214F - 5 = 06%

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1 Craig Andrew Lange Our Document # 1201Taffy (PTP Rating) Impairment & Disability Rating Specialists Voice: (415) / Fax: (415) Luis Pérez-Cordero luis@pdratings.com Employee: William H. Taffy Claim #: Occupation: Grossmont UHSD / Construction Teacher Group #: 214 SS #: NP Injury Date: Birthdate: NP Age: 58 Injury to: Left Upper Extremity Shoulder Med Rpt: (PTP) Steven Stevens, MD / After Consideration of PD Causation Apportionment - LC 4663 MR pg. 3: Does not appear to be any indication for apportionment. Impairment Supported by Exam Findings & Medical History (L) Shoulder ROM: 06 UEI = 04 WPI Impairment Summary and Review LC 4663 Apportionment No Apportionment to avocational factors / preexisting condition. Impairment As Reported (L) Shoulder ROM: 06 UEI (L) Shoulder Strength: 07 UEI (L) Shoulder total: 13 UEI = 08 WPI Recommended Rating supported by correct application of the AMA Guides & 05PDRS 1. If the medical evaluator provides a miscalculation of impairment and the medical report includes objective clinical findings that would support a higher or lower impairment, the AMA Guides allows any knowledgeable observer to adjust the reported impairment accordingly. - Guides 5 th Ed, Ch.2, pg 17 Given that Shoulder Muscle Strength impairment cannot be rated in the presence of painful conditions and decreased range of motion per Section 16.8a strength guidelines, and given Evaluator provides no unrelated pathomechanical cause for (L) Shoulder Strength, Recommended A rating based on (L) Shoulder ROM impairment of 06 UEI = 04 WPI only. A. Rating After Analysis & Consideration of Duplication Among Ratable Factors: Addresses evaluation in Report dated Total Industrial Disability to be Paid for DOI If Occupation # 214, Teacher, Vocational Training [7] 5-214F - 5 = 06% (L) Shoulder ROM Impairments UE Values Are Added Together AMA 5th Edition, Section 164i, pages 474 to 479 Misapplication: ROM Impairment of (L) Shoulder determined before consideration of the unreported ROM figures of the Contralateral Uninjured (R) Shoulder. Flexion / Extension (F) 16-40, p. 476 Abduction/Adduction (F) 16-43, p. 477 Rotation (F) 16-46, pg. 479 Flexion: 165 = 01 Abduction: 160 = 01 Internal: 50 = 02 Extension: 45 = 0.5 = 01 Adduction: 40 = 00 External: 50 = 01 UE To WPI (T) 16-3, p = 04 Whole Person Impairment for PDRS Adjustments: 04 WPI +Excess Pain on ADL --

2 1201Taffy (PTP Rating) Page 2 For comparison purposes only, a rating of impairment as reported by evaluating physician is provided below: B. PD Rating of Impairment As Reported by Evaluating Physician: Addresses evaluation in Report dated Total Industrial Disability to be Paid for DOI If Occupation # 214, Teacher, Vocational Training [7] G - 13 = 16% (L) Shoulder ROM, Strength Deficit & Arthroplasty (Impairment As Reported) AMA Guides Section 164i, pages 474 to 479 Flexion / Extension (F) 16-40, p. 476 Abduction/Adduction (F) 16-43, p. 477 Rotation (F) 16-46, pg. 479 Upper Extremity Flexion: 165 = 01 Abduction: 160 = 01 Internal: 50 = 02 Scale Extension: ROM Adduction: 40 = 00 External: 50 = = 0.5 = 01 Strength Deficit Guides Section 16.8c, Table 16-35, pg UEI Guides, pg. 509: Strength Impairment cannot be used when effort is inhibited by pain Multiply Motion Value by Deficit Percentage UE % Motion Unit & Grade III Deficit Grade IV Deficit (5-25%) Percentage Relative Value (30-50%) Strength Flexion 24 10% 2.4 = 02 Deficit Extension 6 10% 0.6 = 01 Abduction 12 10% 1.2 = 01 Adduction 6 10% 0.6 = UEI Internal R 6 10% 0.6 = 01 External R 6 10% 0.6 = 01 Combined Values 05PDRS, pages 8-1 to C 06 = 13 UE To WPI (T) 16-3, p X.60 = 08 + Excess Pain on ADL (Cannot be For Strength Deficit) -- WPI for PDRS Adjustments 08 WPI Issues in (PTP) Medical Report dated (PTP) Evaluator provides both (L) Shoulder ROM impairment of 06 UEI and (L) Shoulder strength impairment of 07 UEI for a combined total impairment of 13 UEI = 08 WPI in the presence of restricted motion & painful conditions without reporting an unrelated pathomechanical cause for the muscle strength loss. 1.1 Current complaints, MR pg. 2: Mild pain in the left shoulder. Mild pain with lifting, pushing, carrying. No nighttime pain. Does not take pain medication on a regular basis. Has some weakness lifting into the overhead position particularly on a repetitive basis. Has some clicking and popping in the left shoulder, 1.2 Exam, MR pg. 2: Shoulder flexion is 165. Shoulder extension 45. Abduction 160. External rotation horizontal position 60, Internal rotation horizontal position 50. Strength 4.5/5 in abduction, forward flexion, external rotation and with the belly press test. Minimally positive impingement findings

3 1201Taffy (PTP Rating) Page 3 Issues in (PTP) Medical Report dated (cont.) 1.3 AMA 5th Edition Section 16.8a-Principles, pg. 508: Decreased strength cannot be rated in the presence of decreased motion, painful conditions, deformities, or absence of parts... that prevent effective application of maximal force in the region being evaluated. 1.4 AMA Guides, 5th Edition, page 509: Manual muscle testing is subject to individual s conscious and subconscious control. Individuals whose performance is inhibited by pain may not be good candidates for this testing. Results of strength testing should be reproducible on different occasions or by two or more trained observers. 1.5 AMA 5th Edition, Section 16.7d-Tendinitis, pg. 507: If an individual has hand tendon rupture or has undergone surgical release of the flexor or extensor origins of the lateral epicondyles, or has had excision of the epicondyle, there may be some permanent weakness of grip as a result of the tendon rupture or the surgery. 1.6 Principles of Strength Evaluation, Section 16.8a, page 508: If the examiner judges that loss of strength should be rated separately in an extremity that presents other impairments (e.g. ROM Impairment), the impairment due to loss of strength could be combined with the other impairments, only if based on unrelated etiologic of pathomechanical causes. Otherwise, the impairment ratings based on objective anatomic findings take precedence. Definition of unrelated etiologically or Pathomechanics by J. Mark Melhorn Chapter 16 Reviewer & Editor of UE Chapter in the 6 th Edition The concept is that there are many conditions that could result in strength loss, such as damage to a nerve (same etiology), loss of blood supply (same etiology) of fracture healing with malunion (same pathomechanical) that could be rated by other sections. If one of the above occurred and there was muscle loss, then the muscle loss is of a different etiology or a different pathomechanical source for the deficit. The concept is to avoid doubling the impairment. 1.7 (L) Shoulder Stength Conclusion: (AME) Dr. Stevens reports exam findings of Restricted (L) Shoulder range of motion that provides impairment of 06 UEI. There are also current complaints of (L) Shoulder pain. (AME) provides no pathomechanical cause for the (L) Shoulder strength loss that is unrelated to the cause of the decreased range of motion. The (L) Shoulder Impingement, Rotator cuff tear / repair and Biceps tendon tear / repair can impact range of motion along with muscle strength. 1.8 Given that Shoulder Muscle Strength impairment cannot be rated in the presence of painful conditions and decreased range of motion per Section 16.8a strength guidelines, Recommended A rating based on (L) Shoulder ROM impairment of 06 UEI = 04 WPI only

4 1201Taffy (PTP Rating) Page 4 Issues in (PTP) Medical Report dated (cont.) 2. (PTP) Evaluator fails to report or consider uninjured (R) Shoulder ROM impairment in the determination of injured (L) Shoulder ROM impairment. Medical History, MR pg. 2: Past Surgical History: Status post lumbar spine fusion. Status post right shoulder rotator cuff repair 5 years ago. Section 16.4, Evaluating Abnormal ROM, AMA Guides, p. 453: If a contralateral normal" joint has a less than average mobility, the impairment value(s) corresponding to the uninvolved joint can serve as a baseline and are subtracted from the calculated impairment for the involved joint. If there is no indication that the contralateral side has been injured, then the ROM of the contralateral side is considered normal, even if ROM values are less than estimated pie-chart normals: Values Are Adjusted Accordingly. Conclusion: While (PTP) fails to report the contralateral (R) Shoulder ROM in his determination of (L) Shoulder ROM impairment, he does report prior medical history for the (R) Shoulder to include prior rotator cuff repair 5 years ago. Hence, in this case, the ROM of the contralateral uninjured (R) Shoulder is not be considered normal or baseline for this individual given the prior history of rotator cuff repair and rather the AMA Guides estimated normals are used see Figures 16-40, and Permanent Disability Factors of Impairment Evaluator s AMA Impairment Analysis MR pg. 3-4: Utilizing AMA guidelines fifth edition impairment rating was performed. Shoulder flexion of 165 equates to 1% upper extremity impairment. Shoulder extension of 40 equates to a 1% upper extremity impairment. Shoulder abduction of 160 equates to a 1% upper extremity impairment. Adduction of 40 results in 0% impairment. External rotation of 50 equates to 1% upper extremity impairment. Internal rotation of 50 equates to a 2% upper extremity impairment. The patient has lost approximately 10% strength in all directions around his left shoulder. Utilizing table 16-C5 this equates to a 2% impairment for loss of flexion, 1% impairment for loss of extension, 1% impairment for abduction, 1% impairment for adduction, 1% impairment f or eternal rotation, 1% impairment for internal rotation. He, therefore, has a total shoulder impairment of 13%. This equates to an 8% whole person impairment. No separate pain rating indicated. Medical History MR pg. 1-2: Initial surgery performed on 8/22/11. This consisted of shoulder arthroscopy with rotator cuff repair and subacromial decompression. Subsequently surgery was immobilized in a sling for 6 weeks. He then underwent a course of physical therapy. At approximately 5 months after his surgery he was noted to have ongoing pain and weakness in his left shoulder. Based on this a repeat MRI was obtained which showed a recurrent rotator cuff tear, Because of this he underwent a second surgery which was performed on 5/14/12. This consisted of revision rotator cuff repair with biceps tenodesis.

5 1201Taffy (PTP Rating) Page 5 ADL / Current Complaints MR pg. 2: Mild pain in the left shoulder. Mild pain with lifting, pushing, carrying. No nighttime pain. Does not take pain medication on a regular basis. Has some weakness lifting into the overhead position particularly on a repetitive basis. Has some clicking and popping in the left shoulder, Exam MR pg. 2: Bilateral Upper Extremity Head and neck exam is benign. Shoulder flexion is 165. Shoulder extension 45. Abduction 160. External rotation horizontal position 60, Internal rotation horizontal position 50. Strength 4.5/5 in abduction, forward flexion, external rotation and with the belly press test. Minimally positive impingement findings. Vague tenderness over the ac, joint and the subacromial space, Well-healed incision from his biceps tenodesis. Tender to palpation at the site of the biceps tenodesis. No deformity in the biceps muscle, 5/5 elbow flexion and extension strength. Diagnostic Tests MRI of the left shoulder from 7/18/11 shows a 1 cm full-thickness tear of the supraspinatus tendon. Noted to have a spur on the inferior aspect of the acromion. Diagnosis MR pg. 3: Rotator cuff tear left shoulder, Biceps tendinosis left shoulder., Impingement syndrome left shoulder. Luis Pérez-Cordero & Craig Andrew Lange Certified, AMA Guides Impairment & California Disability Rating Specialists American College of Disability Medicine & Board of Independent Medical Examiners Thursday, January 31, 2013

RECIPES FOR RATINGS !!! A. FIBROMYALGIA: 0% WPI P. 569 B. THORACIC OUTLET SYNDROME 0% WPI P. 569 C. MYOFASCIAL PAIN SYNDROME 0% WPI P.

RECIPES FOR RATINGS !!! A. FIBROMYALGIA: 0% WPI P. 569 B. THORACIC OUTLET SYNDROME 0% WPI P. 569 C. MYOFASCIAL PAIN SYNDROME 0% WPI P. RECIPES FOR RATINGS 1. THE "0% WPI" RATINGS A. FIBROMYALGIA: 0% WPI P. 569 B. THORACIC OUTLET SYNDROME 0% WPI P. 569 C. MYOFASCIAL PAIN SYNDROME 0% WPI P. 569 D. TENDINITIS OF UPPER EXTREMITY 0% WPI P.