The employee, Debra Arnold, is 52 years old and currently unemployed. She is receiving Social Security Disability. The employee graduated from high school, attended cosmetology school, and later completed 71 hours of college credits focusing on criminal justice. She did not obtain a degree.
The employee had been last employed with the Department of Corrections as a Correctional Officer I. She was responsible for monitoring meals and recreation, conducting searches, and escorting prisoners. She was employed in this capacity for approximately two and a half years. Her prior employment was as a server at a restaurant and substitute teacher. Prior to that, she stayed at home with her children.
On October 20, 2005, the employee was participating in self-defense training. As part of the class, she had to kick a stationary six-foot dummy at the chest to waist level. She kicked the dummy once, felt an immediate pop and sharp pain in her left knee, and was advised by trainers to rest briefly. She attempted a second kick, which made her symptoms worse. The employee testified that she informed a supervisor of the incident, and informed several staff of the injury, asking for treatment. She testified that her symptoms continued to worsen and that she informed the personnel office staff who told her she had to "wait her turn to see a workers' compensation doctor."
The employee was evaluated by Dr. Mace in June 2006, who diagnosed an acute injury to the left knee, likely an internal derangement, and that the prevailing factor leading to the diagnosis was the injury of October, 2005. She also recommended an MRI, evaluation by an orthopedic specialist, and took her off work completely until MRI results were obtained. She also recommended crutches, and that she be completely non-weight bearing on the left lower extremity. Ms. Arnold was off work beginning on June 22, 2006 due to Dr. Mace's recommendations but was not paid temporary total disability until September 28, 2006.
The Employer then referred her to Dr. Ritchie who ordered an MRI revealing a tear of the ACL. She eventually had surgery, performed by Dr. Ritchie, on September 28, 2006, consisting of an excision of the hypertrophic plica of the anterior medial and anterior lateral plica. Following surgery, the employee was on light duty, attended physical therapy, but reports the knee surgery did not relieve her pain. She also testified and informed Dr. Ritchie that she had ongoing complaints with her right knee, due to the long-standing altered gait. She had additional injections that did not relieve her symptoms following surgery. Dr. Ritchie kept her off work and the employee testified that he did not complete her essential functions from allowing her to return to work. During this time, through the end of 2006, the employee was experiencing ongoing and worsening symptoms in her right knee, and low back.
After requesting a second opinion, the employee was referred to Dr. Johnson who diagnosed patellofemoral pain secondary to quad weakness and abnormal gait. She testified that she had been walking with a cane, held in her right hand, and that the pain was intensifying in her back. Dr. Johnson prescribed aqua therapy and physical therapy. During the course of this therapy Dr. Johnson had her on light duty. This extended period of light duty resulted in the employee losing her job at the Department of Corrections. She applied for and received longterm disability.
By June 2007, the employee was still using a cane and still had restrictions limiting her to sedentary duty. In August she underwent a functional capacity exam which placed her in the light to sedentary demand level. Her job as a CO I was classified as medium level. She continued throughout 2007 to experience low back pain, particularly on the right side due to her altered gait. She also continued to have pain in her right knee due to overcompensation for the left knee.
On June 13, 2008, Mr. Mathieu, Dr. Johnson’s P.A., stated that the employee had reached MMI. He stated that the employee had a 10% rating and her permanent work restrictions were “sedentary only.”
Dr. Volarich evaluated the employee on February 5, 2009. He diagnosed left internal derangement- S/P arthroscopic excision of the hypertrophic plica and redundant synovium, severe postoperative left knee pain syndrome primarily involving the lateral compartment with associated patellofemoral mistracking secondary to quadriceps. He also diagnosed right knee pain syndrome secondary to abnormal weight bearing and lumbar pain syndrome secondary to abnormal weight bearing. He found the accident of October 20, 2005 to be the substantial contributing factor as well as the prevailing or primary factor in leading to these diagnoses. He further assigned a rating of 40% of the left knee, 15% of the right knee, and 15% of the body as a whole referable to the lumbar spine and recommended an evaluation by a vocational expert to assess her ability to return to the open labor market. He outlined extensive restrictions in his report, including an avoidance of all stooping, squatting, crawling, kneeling, pivoting, climbing, and impact maneuvers. He also recommended she avoid uneven terrain, slopes, steps, ladders, and that she limit prolonged weight bearing activities, including standing or walking to 15-20 minutes. He also limited her bending, lifting, pushing, pulling.
Dr. Volarich also outlined a pre-existing condition and diagnosed 3rd and 4th degree burns on her left leg which required skin grafting. He explained that she was burned in an accident in 2003 when she was attempting to put wood in an outdoor furnace. She was treated with skin grafting on her left leg and was advised to use compression stockings. After the accident, she used 100% skin-block when out in the sun and had numbness in her left lower leg. Cold weather irritated the leg, as did extreme heat. She had minimal burning on her hands and wrists, which resolved. Dr. Volarich gave a rating of 7.5% of the left leg referable to these burns.
In his deposition, Dr. Volarich testified regarding the use of a cane and the effect on her complaints as follows, “when a patient has problems like she does and weight bearing and gait is not fluid, meaning normal swing to the arms and normal swagger so to speak, patients continue to have difficulties when they have to use these devises. Whether it’s a cane or a walker or a brace or whatever it might be, they continue to have some sort of problems.”
Dr. Volarich recommended vocational assessment. He found that if vocational assessment was unable to identify a job for which she was suited, then she was permanently and totally disabled as a direct result of the work related injury of October 20, 2005 injury standing alone.
Dr. Volarich stated that the employee will require ongoing care for her pain syndrome using modalities including but not limited to narcotics and non-narcotic medications, muscle relaxants, physical therapy, and similar treatments as directed by the current standard of medical practice for symptomatic relief of her complaints. He also stated that the employee would benefit from treatments at a pain clinic because of her left knee pain syndrome. Dr. Volarich recommended that she see either a physiatrist or pain management specialist to determine the
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cause of her severe lateral compartment knee pain syndrome. He also stated that nerve blocks, trigger point injections, aggressive physical therapy, and similar treatments are all indicated.
The employee was evaluated by vocational expert, James England, at the request of the employee. Mr. England opined that it would be difficult for the employee to compete in the open labor market or to sustain it in the long run.
Mr. England stated that the employee appears to be limited to the point that she is more likely than not going to remain totally disabled from a vocational standpoint. He stated that without a great deal of assistance, he does not believe that the employee could successfully find alternative work on her own. Mr. England also stated that it does not appear that the employee could sustain work even if able to find because of lack of sleep and difficulty being awake, alert and attentive during the day.
Mr. England reviewed the employee's educational and employment background. He noted that the employee often sits with her knee elevated, that she has numbness and pain in her left and right knees and low back, can only stand or walk for 20-30 minutes at the most, and can only sit for around 15-20 minutes. He noted that the employee seldom drives her car. He also noted that the side effects of her pain and sleep medication make her fearful of driving a car. He also noted the job requirements at the Department of Corrections include squatting, bending, climbing. Mr. England stated that the employee had no background using a computer. He also noted that the employee made an effort to obtain other employment or training through the Missouri Division of Vocational Rehabilitation.
After reviewing Mr. England's report, Dr. Volarich reiterated that Ms. Arnold was permanently and totally disabled to the last injury alone.
Sherry Browning evaluated the employee in July, 2010 at the request of the Employer. Ms. Browning concluded that the sedentary restrictions as outlined by Dr. Mace and by the functional capacity exam, preclude the employee from returning to "many of the jobs for which she could have performed otherwise." However, she opined that the employee could return to work at the sedentary level, including customer service representative, receptionist/information clerk, general office clerk, and non-emergency dispatcher. Ms. Browning believed that these positions would allow the employee to change physical positions. Ms. Browning stated that any computer work would be data entry rather than word processing for these positions. Ms. Browning also recommended ongoing education and training.
During the hearing, the employee relayed her complaints and current symptoms as follows: Pertaining to the right knee, she described a constant tightness/squeezing sensation below her right knee cap, a constant need to shift her weight to relieve the pain, a burning sensation in the back of the right knee, and that her pain ranges from a 2 to a 5 on a 10 point scale. Regarding the low back, she experiences constant stiffness and a frequent use of topical pain creams and medicines to relieve the symptoms, she reported that her low back feels like a sunburn with a hot throbbing pain that travels down her left buttocks and often lasts for hours. She reports the pain in her back is never lower than a 5 on a 10 point scale.
Regarding her left knee, she explained popping, swelling, buckling, and that on a good day her pain is at a 4-5 on a 10 point scale. On good days the pain is less intense and that elevating will help the pain. On a bad day she reported pain of at least an 8 , with sharp pain up the side of the knee and down into the foot. She explained a sensation like a bubble in her knee ready to pop, a hot burning feeling, and that symptoms vary depending on weather. She reported that it will frequently give out and buckle, feels weak, affects her balance, and requires her to brace herself on objects as she maneuvers and walks around. She reported that she avoids stairs entirely and that activities like shopping and dish washing are difficult due to the need to walk or stand for long periods.
The employee explained that she never sleeps through the night, that she goes to bed around 9:30 p.m., falls asleep around 11:00 p.m., and is up by 12:00 or 1:00 a.m. to walk around and alleviate the pain. She stated that she averages about 2 hours of sleep at a time and that she will often get up in the middle of the night to get a heating pad or ice pack for her back and knee. She testified that she is "constantly in a fog" due to the lack of sleep, that she cannot concentrate, and has trouble reading.
The employee also testified that she takes pain medicine. She testified that she takes Tramadol, hydrocodone, and ibuprofen. She stated that some months the Employer-Insurer would pay for these medications, and other months they would not pay for the medications. The employee requested $\ 851.00 in unpaid prescription medications.
The employee testified that the brace that was prescribed for her left knee helped, however she was not able to wear it because it irritated her skin due to her prior skin graft.
She testified that she feels she cannot work for many reasons, including the fact that she cannot drive farther than four miles without feeling pain in her back and knees. She cannot concentrate due to sleep deprivation and her medications affect her ability to stay focused. She needs to lay down approximately four to five times per day and she needs to ice her knee and elevate her leg. She further testified that she cannot function or stay on any work task for longer than two hours due to pain. She testified that she applied for and obtained long-term disability, looked for alternative work through vocational rehabilitation, and eventually applied for and received social security disability on her own.