Aaron Carter v. GKN Aerospace Services

On November 14, 2003, as part of his normal job duties, employee was preparing freight to go across the street when he grabbed an empty basket to put parts into. As he started to pull the basket, the wheel fell off the basket and the cart lunged forward on the back of his left heel. The cart weighed approximately 100 lbs . and employee felt immediate pain at the back of his ankle. He had to yank his foot from underneath the cart.

Employee reported his injury and received medical treatment at Concentra. He later went back to work, but continued to have problems with his left foot during the next year. Employee testified that he continued to experience pain and that he would limp 3 to 4 days a week at certain times when he had to be on his feet for long periods. He treated his pain with over-the-counter medications.

Employee did not make any attempt to see a doctor regarding left or right foot pain between November 2003 and January 2005, nor did he ask his employer to send him to a doctor during this period.

In January 2005, employee's left heel pain intensified to the point that it felt like the cart incident happened all over again. Employee testified that in January 2005 he also had extreme pain in his right foot, which he attributed to limping. Employee received treatment at Concentra on his left foot, but was denied treatment for his right foot. He received therapy on his left foot for approximately four months at HealthSouth.

Employee sought treatment on his own for his right foot symptoms with a podiatrist, Dr. Broadhead. Dr. Broadhead found a problem with employee's sesamoid bone and later performed surgery on his right foot in April 2005.

Employee testified that he still has pain in the back of his left ankle and gets tension and pain around his left Achilles tendon. Employee testified that he also still has pain around the ball of his right foot when he is on his feet for long periods of time.

Employee's expert, Dr. A.G. Lipede, opined that both employee's left and right foot injuries were workrelated. Dr. Lipede testified that the left foot injury was caused by the November 14, 2003 work-related injury and that the right foot injury was caused by employee's resulting altered gait. He testified that employee was putting more weight, force and distribution on the weight of the right foot, which created extra force on the big toe or forefoot. Dr. Lipede believes this ultimately resulted in employee's sesamoid bone fracture.

Dr. Lipede is board certified in forensic medicine and disability analysis, but his practice does not include performing surgeries on feet due to orthopedic injuries. Dr. Lipede previously surrendered his medical license in the state of lowa.

On October 23, 2007, Dr. Cantrell examined employee on behalf of employer. Dr. Cantrell diagnosed employee with a contusion and secondary Achilles tendonitis with regard to the left foot injury the employee sustained in November 2003. With regard to the right foot, Dr. Cantrell diagnosed employee with a sesamoid stress fracture, but did not feel it was related either directly or indirectly to the November 2003 left foot injury. Dr. Cantrell testified that he did not think the November 14, 2003 work incident was a substantial factor in causing the right foot condition because employee had no symptoms in his right foot during the course of treatment for his initial left heel injury when he would have expected the gait deviation to be maximal. Dr. Cantrell also noted that employee had been asymptomatic for any left foot or heel complaints in the 6-8 months after conclusion of treatment for the left foot, so there would have been no reason for him to have any gait deviations or limps during this period of time if he was asymptomatic.

Dr. Cantrell further testified that a sesamoid stress fracture would be more likely to be seen in someone who is a runner or dancer and spends a lot of time on the balls of their feet, and it would be less likely to be seen in someone who was limping because they would be spending less time on their forefoot than they would in

a normal walking pattern.

Dr. Cantrell is board certified in physical medicine and rehabilitation and treats individuals who have foot or ankle complaints.

Under Missouri Workers' Compensation law, the claimant bears the burden of proving all the essential elements of his claim, including medical causation. Roberts v. Missouri Highway and Transportation Commission, 222 S.W.3d 322, 331 (Mo. App. 2007). For an injury to be compensable, the evidence must establish a causal connection between the accident and the injury. Id.

In McGraff v. Satellite Sprinkler Systems, 877 S.W.2d 704 (Mo. App. 1994), overruled on other grounds, Hampton v. Big Boy Steel Erection, 121 S.W.3d 220 (Mo. banc 2003), the court stated that "[m]edical causation not within the common knowledge or experience, must be established by scientific or medical evidence showing the cause and effect relationship between the complained of condition and the asserted cause." Id. at 708. Even if supported by scientific medical evidence, "[a] medical expert's opinion must [also] be supported by facts and reasons proven by competent evidence that will give the opinion sufficient probative force to be substantial evidence." Silman v. Williams Montgomery \& Assoc., 891 S.W.2d 173, 176 (Mo. App. 1995), overruled on other grounds, Hampton v. Big Boy Steel Erection, 121 S.W.3d 220 (Mo. banc 2003). Further, "[a]ny weakness otherwise present in the underpinnings of the opinion given by the [expert] witness goes not to the admissibility of the testimony but to its weight and value." Hall v. W.L. Brady Investments, Inc., 684 S.W.2d 379, 388 (Mo. App. 1984).

In this case, employee alleged that the November 2003 injury to his left heel caused him to alter his gait, which ultimately led to a sesamoid stress fracture in his right foot. Employee provided medical evidence and testimony from Dr. Lipede that supported this theory.

Dr. Lipede's medical evidence and testimony lacks probative value. First of all, Dr. Lipede may be board certified in forensic medicine and disability analysis, but his practice does not include performing surgeries on feet due to orthopedic injuries. Secondly, Dr. Lipede failed to acknowledge that employee had a normal gait when he was discharged from care at Concentra on November 26, 2003. Dr. Lipede's understanding was that employee was walking with a significantly altered gait during that time period. Dr. Lipede assumed a fact that is not corroborated by the medical evidence. Lastly, Dr. Lipede surrendered his medical license in the state of lowa, and faced multiple charges in other states. All of these factors affect the credibility of Dr. Lipede's findings and testimony.

On the other hand, Dr. Cantrell's medical evidence and testimony provides a much more logical rationale to support his opinion that employee's sesamoid stress fracture was not related either directly or indirectly to the November 2003 injury.

First of all, Dr. Cantrell is board certified in physical medicine and rehabilitation and treats individuals who have foot or ankle complaints. Secondly, Dr. Cantrell noted that employee did not have any symptoms in his right foot during the course of treatment following the initial left heel injury in 2003 when he would have expected employee's gait deviation to be maximal. Thirdly, Dr. Cantrell noted employee had been asymptomatic for any left foot or heel complaints in the 6 to 8 months after the conclusion of treatment following the initial injury in 2003. Dr. Cantrell reasoned that during this time period that there would not have been a reason for him to have any gait deviations or limping if he was asymptomatic in the left foot. Additionally, Dr. Cantrell noted that employee had not presented with any right foot complaints until January 2005, at which time there was not any documented history of ongoing limping as a result of left heel pain and no reason to believe that employee would have had a gait deviation sufficient to cause a sesamoid stress

fracture. Lastly, Dr. Cantrell testified, as a physician that treats individuals with foot or ankle complaints on a regular basis, that a sesamoid stress fracture would be more likely to be seen in someone who is a runner or dancer and spends a lot of time on the balls of their feet, and it would be less likely to be seen in someone who was limping because they would be spending less time on their forefoot than they would in a normal walking pattern.

The administrative law judge did not make a credibility finding as to Drs. Lipede and Cantrell, nor did he provide a thorough legal analysis to support his determination that employee's right foot injury was workrelated. The administrative law judge's award merely finds in a conclusory manner that employee's right foot injury was caused by his altered gait.

The Commission, based on the totality