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Case 1
A 32 year-old male house painter fell from a ladder 19 months ago. He began having acute low
back, left buttock and left posterior thigh and calf pain; left neck, shoulder girdle and arm pain;
and left ankle pain.
A lumbar MRI scan that showed a posterolateral left L5/Si HNP, touching the left Si nerve root.
Plain film x-rays reveal bilateral pars defects and a Grade I isthmic spondylolisthesis at 15/Si
with moderate spondylosis, but no evidence of segmental instability or alteration of motion
segment stability on flexion and extension views. A cervical MRI scan was obtained which
revealed a foraminal disc extrusion at C4/5, compressing the left C5 nerve root. An MRI scan of
the ankle revealed some mild increased signal of the anterior talofibular ligament (ATFL),
consistent with an inversion sprain.
He underwent two lumbar epidural steroid injections and 38 visits of physical therapy for his
lower back, neck and left ankle. His symptoms and function improved and he has been able to
return to his job 15 months ago. However, he still experiences neck and left shoulder pain with
painting overhead and lifting buckets of paint, as well as low back and left buttock pain with
prolonged sitting, repeated bending forward or lifting.
Current lumbar physical examination shows lumbar range of motion that meets the validity
criteria as follows: flexion of 54 degrees (with a sacral value of 30) without dysmetria, lumbar
extension of 21 degrees, right lateral flexion of 18 degrees and left lateral flexion of 25 degrees.
Left straight leg raise is limited to 44 degrees where it produces left low back and left buttock
pain, further increased with ankle dorsiflexion. Right SLR is accomplished to 53 degrees limited
by hamstring tightness. The left Achilles DTR is decreased and there is numbness to pinprick
over the left lateral foot. There is some weakness to repetitive calf raises and there is 2 cm of
calf atrophy on the left.
Current cervical physical examination shows cervical flexion 30 degrees, extension 40 degrees,
right lateral flexion 30 degrees, left lateral flexion iS degrees, right rotation 60 degrees and left
rotation 40 degrees. Spurling’s test produces some left posterior neck and left shoulder pain
with moderate tenderness over the left cervical paraspinal muscles. There is 2 cm of atrophy of
the left bicep and the left bicep reflex is 1+. The right upper extremity deep tendon reflexes are
2+ and sensation and strength are normal.
Current ankle physical examination shows a slight limp and decreased stance phase with left leg
weight bearing. There is no swelling, focal tenderness to palpation, or pain produced with
passive ankle inversion. Ankle ROM is dorsiflexion 10 degrees, and plantar flexion 30 degrees.
Hindfoot motion inversion 20 degrees and eversion 10 degrees. Weight bearing and stress x
rays of the ankle are not available for review.
2
The accepted/compensable injuries listed on the DWC 32 are lumbar, cervical and left ankle
sprain/strain; 15/Si and C4/5 disc herniations. The carrier has denied bilateral pars defects and
a Grade I isthmic spondylolisthesis at L5/S1 with moderate spondylosis.
Questions:
Has MMI been reached; if so, on what date (may not be greater than the statutory MMI date
shown above)?
If not at MMI, what is needed to reach MMI?
If at MMI:
As of the MMI date, what is the IR?
Is any referral and/or additional testing needed?
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CD
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Case 1
A 45 year old electrician fell from a ladder 23 months ago. He attempted to keep from falling
by holding onto metal conduit. He complained of neck, right shoulder and arm pain, plus low
back and left leg pain.
MRI scans of the neck and shoulder revealed a partial thickness tear of his right rotator cuff,
small subacromial and clavicular osteophytes, and a right C5/6 extruded disc herniation. A
lumbar MRI scan revealed disc dessication and a broad based 2 mm central disc bulge at 15/Si
without nerve root or thecal sac compromise. There were no correlating findings of lumbar
radiculopathy on electrodiagnostic studies. However, there were pre-operative EMG findings
consistent with a right C6 radiculopathy.
Conservative treatment included NSAIDs, muscle relaxants, subacromial injection xl, cervical
ESl xi, and physical therapy all without lasting benefit. He underwent a C 5/6 ACDF 17 months
ago. He also had an arthroscopic rotator cuff repair with an acromioplasty and partial resection
of the distal clavicle, per the operative report, ii months ago. He underwent 40 visits of
physical therapy following both the ACDF and shoulder surgeries and was discharged from
physical therapy 2 months ago.
His symptoms have improved but he says he still experiences neck and right shoulder pain. His
low back and left lower extremity symptoms have also improved somewhat, however, he
continues to complain of low back and bilateral buttock pain with prolonged sitting, bending
forward, and/or lifting. Restricted duty is not available and he has not returned to work.
Current Oswestry score is 48%, his QuickDASH score is 30, and a pain drawing shows low back
and bilateral buttock pain; bilateral neck pain and right shoulder girdle and upper arm pain,
rated as a “6” of 10.
Your DD lumbar exam shows lumbar flexion of 64 degrees (with sacral value of 35 degrees)
without dysmetria, lumbar extension of 21 degrees, right lateral flexion of 18 degrees and left
lateral flexion of 25 degrees. There is no palpable muscle spasm. Lower extremity deep tendon
reflexes, sensation and strength are normal. There is no atrophy. Straight leg raise is
accomplished to 45 degrees on the left where it reproduces low back pain, without ankle
dorsiflexion aggravation. Straight leg raise is 55 degrees on the right, limited by hamstring
tightness.
Your DD cervical physical examination shows cervical flexion 30 degrees, extension 40 degrees,
right lateral flexion 15 degrees, left lateral flexion 30 degrees, right rotation 40 degrees and left
rotation 60 degrees. Spurling’s test produces some right posterior neck pain. There is moderate
tenderness over the right cervical para spinal muscles. There is 2 cm of atrophy of the right
forearm and the right brachioradialis reflex is 1+. Upper extremity sensation and strength are
normal. His post-operative x-rays (12 months post-op) show a healed fusion, with intact
hardware and no evidence of instability or pseudoarthrosis on flexion/extension views.
2
Current shoulder physical examination shows active right shoulder ROM as follows: flexion 160
degrees, extension 40 degrees, abduction 140 degrees, adduction 50 degrees, internal rotation
60 degrees and external rotation 40 degrees. His left shoulder ROM is full. Pulses are normal
and there is no atrophy.
The accepted/compensable injuries listed on the DWC 32 are 9umbar, cervical and right
TM and there are no disputes noted in the medical records sent for review.
shoulder
Questions:
MMI:
Has MMI been reached; if so, on what date (may not be greater than the statutory MMI date
shown above)?
If not at MMI, what is needed to reach MMI?
IR: (if at MMI)
As of the MMI date, what is the IR?
Is any referral and/or additional testing needed?
RTW:
Is the injured employee able to return to work in ycapacity and what work activities can the
injured employee perform? (no date range is listed per the DWC 32)
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