This fifty-one year old claimant's work involved general carpentry and construction regularly using hand and power tools, including hammers, power saws, drills and screw guns. He developed numbness in his right hand and fingers and his left hand would also go numb with extended use. His right hand symptoms were more severe than his left.
On June 15, 1998, the claimant consulted Dr. Michelle Koo for discomfort, pain, numbness, and tingling in his right and left hand as well as left elbow pain. Dr. Koo diagnosed bilateral carpal tunnel syndrome, which she noted to be aggravated by his work activities. She also diagnosed some left lateral epicondylitis, which is also related to his work activities. She noted he had no pain in his right lateral medial epicondyle on examination of his elbow. She recommended nerve conduction studies and administered bilateral carpal tunnel injections. On July 20, 1998, bilateral nerve conduction studies revealed median neuropathy affecting motor and sensory conduction at the right carpal tunnel. Left median and right and left ulnar nerve conduction studies were normal. On September 15, 1998, Dr. Koo performed a right endoscopic carpal tunnel syndrome release. She last examined the claimant on January 15, 1999, and opined
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that he had very good relief of his preoperative symptoms, except for on the radial aspect of his ring finger, which still tingled somewhat. All other fingers were noted to have good relief of all of the symptoms. She noted minor tenderness on very deep palpation in the mid-palm area, with excellent grip strength and range of motion. She concluded he was at maximum medical improvement for his right hand and that he would not need any further intervention. Regarding his left hand symptoms, it was noted he was not numb and tingling all of the time and that he would wait until his symptoms progressed, or at least a year from his right hand surgery. Dr. Koo released the claimant from her care.
On December 1, 1999, Dr. Sudekum examined claimant for right hand and wrist symptoms and recorded a history of the 1998 right endoscopic carpal tunnel release and noted since his surgery he had pain in the area of the incision on the volar aspect of the wrist that radiated approximately into his forearm, elbow, and upper arm. Dr. Sudekum also noted that one month before this exam, the claimant began experiencing symptoms of numbness and tingling in ring and little fingers as well as decreased grip strength and nocturnal pain. Dr. Sudekum opined that the claimant had clinical symptoms of right ulnar neuropathy with the probable sign of injury or compression at the wrist and possibly the elbow. He opined that the ulnar neuropathy was a work-related condition due to the nature and duration of his employment as a carpenter. A December 15, 1999, bilateral nerve conduction study was consistent with bilateral carpal tunnel syndrome and a lesion, nerve compression, at the right Guyon's canal. Dr. Sudekum performed a steroid injection to both carpal tunnel regions. Dr. Sudekum also recommended right ulnar nerve decompression at the elbow and wrist as well as revision open carpal tunnel release. On February 16, 2000, Dr. Sudekum noted claimant's left hand pain and numbness had resolved completely and his right-sided symptoms improved significantly. He opined that surgery was not indicated at that time, but may be required in the future if symptoms reoccur.
On May 10, 2000, Dr. Sudekum noted recurrence of pain in claimant's right palm and intermittent numbness and tingling in the thumb and all four fingers. He also noted complaints of tenderness in the right lateral epicondylar region. Dr. Sudekum performed a surgical incision into his right lateral epicondylar region. Dr. Sudekum last saw claimant on December 5, 2000, for increasing pain and paresthesias in his hands, wrists, and forearms. He noted claimant had constant numbness in his right ring and little fingers, significant grip strength weakness and an inability to hold on to objects like a hammer. Intrinsic muscle atrophy of the right hand was noted, consistent with severe ulnar neuropathy. Surgery was scheduled to include a right open carpal tunnel revision, right open carpal tunnel release, as well as right ulnar nerve release at the wrist and elbow.
On December 20, 2000, Dr. Ollinger examined the claimant and diagnosed (1) postoperative endoscopic decompression right carpal tunnel 09/15/98; (2) atrophy in the right ulnar innervated hand musculature; (3) right tennis elbow, which he said was onset one year ago. On December 20, 2000, Dr. Phillips performed an NCV/EMG to compare with prior data revealing a severe right ulnar neuropathy, with the findings most consistent with localization at the level of the wrist. Dr. Phillips suspected that the median neuropathy represents residual from previously more severe involvement. The test also revealed moderate left carpal tunnel syndrome.
On January 3, 2001, Dr. Ollinger opined that the claimant's severe right ulnar tunnel compression neuropathy was related to his employment but not associated with the January 1, 1998, date of loss. He concluded the right ulnar nerve compression at the wrist developed sometime after Dr. Koo discharged the claimant on January 15, 1999, and, as such, not related to that date of loss. He noted the left carpal tunnel syndrome was an active condition needing operative decompression and that this condition did relate to the January 1, 1998, date of loss. He also commented that claimant's right tennis elbow was not referenced until Dr. Sudekum's record of May 2000 and, although work-related, was not related to the January 1, 1998, date of loss.
Dr. Ollinger performed a right ulnar nerve decompression on January 16, 2001. He continued to treat the claimant through February 21, 2002, with five postoperative visits. He released the claimant to return to work with no restrictions on March 12, 2001. Dr. Ollinger noted on this visit that the claimant's muscle mass of the ulnar nerve innervated intrinsic muscles was improving. He continued to have sensitivity and slight pain in his palm, especially with gripping and tenderness in the ulnar palm if it is bumped. He noted cramping in his thumb after gripping all day long and some residual tingling and numbness, which was a bit more noticeable in the past six months. His entire little finger and ring finger distal to the PIP showed clear improvement from his pre-operative condition. Regarding the left hand, claimant described no tingling or numbness and had no night symptoms. His symptoms at that point involved general wrist pain with heavy use, which included a lot of twisting. Dr. Ollinger noted both of claimant's hands were very heavily callused and dirty, consistent with heavy use.
On February 27, 2002, Dr. Phillips performed another EMG/NCS study revealing significant improvement in the right ulnar nerve study and significantly increased strength and muscle bulk. "This study is not impressive for activity and the degree of improvement that occurred is impressive. There has been further improvement in the right medial nerve values across the carpal tunnel. There is evidence for only mild left median neuropathy across the carpal tunnel." Dr. Ollinger concluded the claimant was at maximum medical improvement, although there may be some additional improvement over a prolonged period of time. Regarding the left upper extremity, he opined that the claimant had no specific symptoms of carpal tunnel and that his physical examination was not impressive for this condition. The NCS studies revealed only mild median neuropathy across the carpal tunnel and he concluded claimant had very mild left carpal tunnel syndrome. He opined that the claimant was at maximum medical improvement for this condition as well.
On August 30, 2002, Dr. Brown examined the claimant for an independent medical evaluation of his right arm. The claimant continued to have numbness in the right hand, little finger, ring finger, and middle finger. He also complained of pain over the volar aspect of his right wrist and a lump in the right palm. Dr. Brown noted some of the claimant's symptoms may be residual from a severe ulnar neuropathy of the right wrist, however he had positive Tinel's over the cubital tunnel on this exam. Repeat nerve conduction studies on October 2, 2002, revealed improvement of the right medial distribution consistent with decompression with mild residual symptoms. The test was not impressive for right ulnar neuropathy across the elbow and revealed substantial improvement in the right ulnar nerve responses. He opined that the claimant's palm pain relates to scar tissue but offered no further treatment recommendations for the right wrist.
On March 24, 2003, Dr. Brown evaluated the claimant's left arm. The claimant reported that over the past six months he started waking up at night with a numb left hand. An April 1, 2003, NCS/EMG study was consistent with mild-moderate left sensory motor carpal tunnel and borderline mild left ulnar neuropathy across the cubital tunnel. The claimant returned to Dr. Brown on April 11, 2003, and was told to wear a Heelbo pad over his left elbow and wear a wrist splint over his left wrist at night and sleep with his elbow in an extended position. On June 13, 2003, the claimant reported that overall, his left hand was doing better. He still had some intermittent numbness in his left hand. Dr. Brown noted that claimant's symptoms were much improved since he had been off work for an unrelated low back condition. Since he was minimally symptomatic at that point, he recommended observation and to see him on an asneeded basis. Dr. Brown continued him on full duty with no restrictions.
The claimant continues to experience right hand numbness and tingling in three fingers. His right index finger is cold all the time, especially in cold weather. He continues to experience pain in his right wrist when working with hammers and saws. He has right elbow symptoms, associated with flare-up of his carpal tunnel, which can last a couple of days. He also testified that he experiences left hand numbness if he holds on to an object for too long. He also experiences symptoms in his left elbow when he does any activities with his left hand. With regard to grip strength, he testified that his right hand is very weak but his left hand is not as bad. He has difficulty using a fork with his right hand. He testified that his hands cramp up if he uses a keyboard for too long, especially the right side. He is on no prescription medication but takes Ibuprofen for back pain.
He continued to operate Berra Construction on a full-time basis through 2006, but then went to work for McMillan Contracting as a project manager, which does not require as much physical hand intensive work. Part of the reason he left was because he could no longer perform some of his job duties, including framing due to the condition of his hands and low back.
Dr. Koo
On January 25, 1999, Dr. Koo examined the claimant for his status-post right endoscopic carpal tunnel release and opined that he had excellent relief of his preoperative symptoms, except for on the radial aspect of his ring finger, which still tingled somewhat. His sensation was completely intact as to all of his fingers and thumb and static two-point discrimination was 5 mm throughout, including the radial aspect of his ring finger. Mild tenderness on deep palpation in his right mid-palm was noted. He had excellent grip strength and range of motion. Dr. Koo opined that the claimant had a 6 % permanent partial disability of the right wrist. He was returned to work with no restrictions.