At the time of his accident on January 19, 2001, Michael W. Scott was working as a forklift operator for Advance Logistics, LLC. Although the employer-insurer questioned the employee's version of the accident, the employee testified that his injury occurred when he was lifting a manual battery changer in order to change the battery in his forklift. The employee stated that when he lifted the battery changer, he felt pain shoot through his shoulder and arm. He stated that it felt like "someone had put a wedge in there and was trying to tear my arm off."
After reporting his accident, the employee was authorized by the employer to seek medical treatment. The medical records from Southeast Missouri Hospital, Occupational Medical Services, Southeast Patient Rehab, Cape Imaging, MidAmerica Rehab and Dr. Herbert Haupt all confirm that both the employee and the health care providers believed the employee had suffered an injury to his right shoulder (Employee's Exhibit A, B, C, D, E, F and G and Employer-insurer's Exhibit 1).
The emergency room physician at Southeast Missouri Hospital diagnosed the employee as having an acute right shoulder and pectoralis strain. The employee told the emergency room doctor that he felt a pop and pain in his right shoulder. The emergency room physician ordered x-rays of the employee's right shoulder that were negative (Employee's Exhibit A). The employee was subsequently treated by Sarah Froemsdorf, who is a nurse practitioner with Occupational Medical Services. The employee gave a history of his right shoulder popping, with pain that ran into his arm. The employee was diagnosed as having a right shoulder strain. A subsequent MRI was negative for any rotator cuff or labrum tear (Employee's Exhibit E). None of the early medical records from Occupational Medical Services indicate the employee ever complained of neck pain or other symptoms that would typically be associated with a herniated disc in his cervical spine (Employee's Exhibit C).
The Cape Imaging MRI report dated March 13, 2001 also indicates both the employee and the health care providers believed the employee had injured his right shoulder. In his clinical history taken prior to the MRI of the employee's right shoulder, the radiologist recorded the employee's comments as follows:
The patient was injured on January 19, 2001. He states he was injured at work. He suggests that this represented a twisting and/or hypertension injury. He has not had any previous surgery or fracture involving this joint. He has multiple symptoms to include pain, swelling, limitation of motion, and a sensation that the joint gives out.
(Employee's Exhibit E.)
The physical therapy records from Southeast Outpatient Rehab indicate that in January and February of 2001, the employee received approximately ten sessions of occupational therapy and 20 sessions of physical therapy. These records also indicate that neither the employee nor the therapist felt the employee had suffered any injury to his neck or cervical spine. The employee's primary, recurring complaint was of pain, popping, soreness or aching in his right shoulder. The therapy records do note that on a few occasions, the employee experienced pain that went from his upper arm into his forearm and numbness in his right arm (Employee's Exhibit D).
When the conservative treatment from Nurse Practitioner Froemsdorf failed to resolve the employee's complaints of right shoulder pain, the employer authorized additional treatment with Dr. Herbert Haupt, who is an orthopedic surgeon in St. Louis, Missouri. Dr. Haupt first saw the employee on April 11, 2001, with a chief complaint of right shoulder discomfort. Based on his physical examination and his review of the MRI, Dr. Haupt concluded the employee had strained his right shoulder. Dr. Haupt felt that the employee had received appropriate rehabilitation, and recommended he be allowed to return to his functional activities at work while maintaining a home exercise program (Employer-insurer's Exhibit 1, page 7-9).
The employee saw Dr. Haupt again on May 2, 2001, with continued complaints of soreness in his right shoulder. The employee was maintaining his full work duties, but was experiencing discomfort at night while sleeping. Dr. Haupt then prescribed additional physical therapy at Mid America Rehab to strengthen the scapular stabilizers around his shoulder blade (Employer-insurer Exhibit 1, page 11).
The initial evaluation at Mid America Rehab on May 4, 2001, is consistent with the other medical records. The employee complained of right shoulder pain and weakness, and reported that he had injured his shoulder on January 18, 2001 while lifting a battery chain. The employee stated that he had a constant ache with occasional sharp pain in the posterior aspect of his right shoulder. Once again, the employee did not report any neck pain or other symptoms to indicate he might have been suffering from a herniated cervical disc (May 4, 2001 evaluation in Employee's Exhibit F).
On May 9, 2001, however, the employee reported that, in addition to soreness in his shoulder, he had "intermittent feeling of hitting my funny bone." He described this sensation as "pins and needles that comes and goes down