Based on the above exhibits and the testimony presented at the hearing, I make the following findings:
- The claimant began her employment with Meramec Group, Inc. (the employer), on September 22, 2003. The claimant is approximately 5 feet 3 inches tall, and weighs about 170 pounds.
- The claimant works on the first work shift, which runs between 7:00 a.m. and 3:00 p.m. She has a 20-minute lunch break and two 10-minute breaks. The claimant was laid off during the period of October 2006 to January 2007. When she returned to work in January 2007, she worked for the Industrial Products Division of the employer. This division makes mats, arms for computer chairs, and Omnis. An Omni is a foam cushion in which a person's face is placed during back surgery.
- On or about September 30, 2007, the claimant was working on a manufacturing line that was produced the foam Omnis. The employer fulfilled two contracts for producing Omnis in 2007, and each contract took approximately four weeks to complete.
- While on the Omni line, the claimant's duties included spraying the molds that make the products, closing the lids on the molds, and operating a panel that places the material in the molds. Both the spraying and the opening of the molds are accomplished by the claimant pushing a button; a robot/machine does the actual spraying and opening. When the molding process was completed, the claimant would push the Omni in on all sides to loosen it from the mold. Then, she would manually remove the products from the molds. Next, she would knead the Omnis to make them softer. The claimant would also trim and pack the products.
- The kneading action used in making Omnis involved pushing and squeezing the products with both hands. The claimant testified credibly that the kneading required her to exert significant force. She performed this task on a work table; one of the tables hit her a little above her belly button, and the other hit her a little below her belly button. She would push down on the Omnis, often while standing on tip toes, as she was leaning over the work table. She would use both arms and shoulders as she pushed down on the front and back of the Omni, and then she would turn it over and push down on the front and back again. The claimant had to be careful not to squeeze too hard or she could leave a handprint on the Omni, making it unusable.
- Making Omnis does not involve overhead work or work at the shoulder level.
- The claimant's quota was to make 30 boxes of Omnis per shift. There are six Omnis to a box. Thus, the total number of Omnis she was required to make each shift was 180, but she would often make up to 200. With the help of a coworker, the claimant usually made between 29 and 33 boxes of Omnis a day.
- While making Omnis in September 2007, the claimant worked with co-worker Kathy Whitworth. During the first three and one-half weeks of the four-week production period, the claimant would knead all four Omnis from each batch, while Ms. Whitworth sprayed the molds and trimmed excess from the finished Omnis. This made production go faster. This division of labor was by agreement of the claimant and Ms. Whitworth.
- After the initial three and one-half weeks, the claimant and Ms. Whitworth altered their habit so that they each kneaded two Omnis per batch of four.
- In mid-September 2007, the claimant began to experience bilateral shoulder problems. She felt that the left shoulder symptoms were caused by the process of making Omnis.
- On October 18, 2007, the claimant told her supervisor, John Crnkovich, that her left shoulder was hurting from making the Omnis for so long. That same day, she filled out an Employee Injury Report. She listed the date of injury as October 2, 2007. She indicated that while her arms had hurt for a while, she had thought that they would get better. In her Claim for Compensation, the claimant listed the date of injury as September 2007.
- By October 18, 2007, the claimant's right shoulder complaints had disappeared. Her left shoulder, however, still hurt.
- The employer/insurer sent the claimant to see Dr. Sandra Tate for an independent medical exam in November 2007. Dr. Tate felt that there was nothing in the claimant's job duties that appeared to be a prevailing factor in her current symptoms. She did not provide treatment
- The claimant therefore went to her own doctor, Dr. Matthew Tiefenbrunn of Family First Clinic. He x-rayed claimant's shoulder and found it to be inflamed. He prescribed medications.
- On February 20, 2008, the claimant went to see Dr. William Sedgwick, a board-certified orthopedic physician. He performed an examination and reviewed x-rays. He noted that the claimant has symptoms and findings consistent with subacromial bursitis/supraspinatus tendinitis. Dr. Sedgwick also noted that rotator cuff pathology and long head of biceps pathology cannot be excluded. He indicated that repetitive activity such as that described by the claimant to have occurred in October 2007, involving the use of the shoulders, is the type of
activity that is known to cause or contribute to subacromial bursitis, tendinitis, and even rotator cuff tearing, as well as bicipital tendinitis. He recommended that she undergo an MRI. In his opinion, the claimant's work was the prevailing cause of her left shoulder symptoms.
- Dr. Sedgwick ordered an MRI of the claimant's left shoulder. The MRI was performed on or about March 25, 2008. The MRI report revealed a type III acromion. In addition, there was tendinosis of the supra and infraspinatus with at least partial thickness apparent bursal sided tearing of the supraspinatus near its insertion as well as some partial thickness intrasubstance tearing.
- On August 5, 2008, Dr. Sedgwick opined that the claimant would benefit from an arthroscopy of the left shoulder with acromioplasty and a rotator cuff debridement or repair, depending on the extent of the partial thickness tear. In Dr. Sedgwick's opinion, the claimant's work activities were the prevailing cause of her shoulder problems.
- Dr. Tiefenbrunn sent the claimant to Dr. Rotramel, who gave her a cortisone shot in her left shoulder on April 24, 2008. Although the shot helped for two weeks, the claimant's left shoulder again became painful.
- The employer/insurer then sent the claimant to Dr. Milne for an independent medical evaluation. Dr. Milne examined the claimant on June 17, 2008. His diagnosis was left shoulder rotator cuff tendinitis. Dr. Milne opined that as there did not appear to be any overhead motions involved in the claimant's job, he did not find that her employment was the primary and prevailing factor in her need for additional treatment.
- In his October 2, 2008, Addendum to his rating report, Dr. Milne noted that he had reviewed additional medical records and the MRI scan performed on the claimant. He noted that the MRI showed that the claimant has a type III acromion and possible partial thickness bursal sided tearing and rotator cuff tendinosis. He reiterated his opinion that he does not feel that the claimant's employment is the primary and prevailing reason for her to need additional treatment, although he does not doubt that she might respond favorably to a subacromial decompression. In his deposition, he indicated that it would be reasonable to perform the surgery, although he did not believe that it was related to her work.
- At the time that Dr. Milne examined the claimant in June 2008, she had been on FMLA leave (under the Family Medical Leave Act) and had not been working. It was not clear whether the doctor realized or recalled that fact when he drafted his report.
- Currently, the claimant experiences left shoulder pain. This pain bothers her at night, and sometimes wakes her from sleep. During the day, the claimant takes Tylenol for the pain. Her left shoulder problems affect her at work. Her shoulder pops often and is sore. Because of her left shoulder complaints, the claimant no longer vacuums or swims. Swinging her arms while walking causes shoulder pain. The claimant can perform overhead activities, but they are painful. In addition to the limitations of motion, the claimant has a loss of strength in her left shoulder.
- Mr. Crnkovich, the claimant's supervisor, testified that in his opinion, squeezing and pushing the Omnis did not require a great deal of force. He acknowledged that he is approximately 6 feet 3 inches tall and weighs about 250 pounds.
- Dr. Sedgwick was asked whether everyday, normal activities, such as picking up groceries, doing laundry, and driving would cause an otherwise normal individual with a type III acromion to have symptoms. He responded "not always. It depends on the condition of the surrounding musculature, how much laxity they have in their joint." He did add that a type III acromion does predispose a person to impingement and pain with these types of activities.
- During re-direct examination, Dr. Sedgwick again addressed the claimant's need for medical treatment:
Q (employee's attorney): And in any event, even if we assume as Mr. Banahan has alluded that she might have had rotator cuff tendinitis at some
point in 2005, that wouldn't alter your opinion that the work
activities that she described in connection with her complaints in 2007 are the prevailing factor in the need for her medical treatment that you are recommending. Is that accurate?
A (Dr. Sedgwick): That's correct assuming the facts that we've already been through them.
- Dr. Sedgwick testified credibly and convincingly that the claimant's condition/pathology can occur in the absence of the use of the arms overhead. He stated that impingement frequently occurs in an overhead position, such as when throwing or hitting a tennis shot or swimming. But, he explained, it can also occur in a midarc range of motion, and it can occur any time longitudinal force is applied to the shoulder with the arm in a slightly abducted position. That is, impingement can occur in an abducted position and this is similar to the type of activity that the claimant described to him.
- In a letter dated May 11, 2005, Dr. James Coyle noted that the claimant was seen for a follow-up; the claimant was three months postoperative C5 through C7 anterior cervical diskectomy and fusion. He noted that her numbness in her upper extremities is improved, and that she does have mild rotator cuff tendinitis in her left shoulder. This is the only reference to rotator cuff tendinitis in Dr. Coyle's records. The basis for Dr. Coyle's statement regarding the claimant's rotator cuff is unclear. The claimant testified that Dr. Coyle did not treat her left shoulder.
- In his deposition, Dr. Sedgwick acknowledged that if Dr. Coyle's May 2005 reference to the claimant having mild rotator cuff tendinitis was a correct diagnosis, that this might change his opinion as to what was the prevailing factor in causing her condition. That is, he would then say that the work activity was an aggravating factor. He also indicated that he does not have any idea as to what the basis was for Dr. Coyle's conclusion that the claimant was suffering from mild rotator cuff tendinitis in 2005.
- Dr. Milne testified that the claimant's work was not the prevailing or primary factor "because she has this large type III acromion, which is part of how she's built," and because she did not perform any overhead work.
- Dr. Milne, however, did acknowledge that patients can have rotator cuff problems or tearing without overhead work. He also indicated that although people with rotator cuff problems often have a type II or type III acromion, he doesn't think you can say that the type II or type III acromion makes one more likely to tear a rotator cuff. Instead, he indicated that rotator cuff tears are "associated" with type II or type III acromions; the two things are often found together. In Dr. Milne's opinion, a 45-year old person with a type II acromion "has probably a 45 percent chance of having this problem if they live in a bubble."
- Dr. Milne acknowledged that he has never seen a demonstration of how the claimant performed the kneading function of her job. When asked whether it would have been helpful to have had a better description of the claimant's job when he was reaching his opinion, he responded that "[i]t could have been, but the patient was asked and she answered that she didn't work at or above shoulder level." Thus, Dr. Milne again placed significant importance on the fact that the claimant's work did not involve tasks at or above the shoulder level.
- In April 2006, prior to the current injury, the claimant treated for anterior chest and left shoulder blade discomfort, along with difficulty breathing. Also in April 2006, the claimant mentioned left shoulder pain to Dr. Tate. The claimant credibly testified that the shoulder complaints that she suffered in 2006 were different in nature from those she experienced in 2007 and 2008. In April 2006, she had a sharp pain in her chest that radiated into her left shoulder. The claimant testified that those symptoms resolved. The shoulder pain in 2007 and 2008 did not involve pain in her chest or difficulty breathing. In Dr. Sedgwick's opinion, the shoulder symptoms the claimant had in 2006 were in a different area and were not related to any ongoing problem she is having now.