review of previous operative notes, there was basically no significant intra-articular pathology in the past. From a diagnostic standpoint, I feel an MRI arthrogram is warranted. If there is significant abnormality of the biceps anchor and labrum or the rotator cuff, I would believe that the [July 2, 2008] injury he describes is the prevailing factor in the development of these lesions. If the MRI arthrogram is negative, other than some tendinopathy and/or changes in the subacromial space, I would feel that his pre-existing disease is the primary factor in his present discomfort.
Following the MRI arthrogram, performed on July 29, 2009, Dr. Hulsey noted that the MRI demonstrated a "[l]arge supraspinatus complete rotator cuff tear." This finding is sufficient to confirm Dr. Hulsey's opinion, set forth above, that the July 2, 2008, injury was the prevailing factor in causing employee's medical condition and disability.
Dr. Hulsey's operative notes reveal that the problem actually appeared to be in the labrum and biceps tendon, rather than the rotator cuff. However, the operative findings are still sufficient to establish the July 2, 2008, injury as the prevailing factor. The labrum and biceps tendon were two of the possibilities, along with the rotator cuff, that Dr. Hulsey considered on May 13, 2009.
With respect to permanent partial disability, Dr. Hulsey opined that employee has a total of 20% permanent partial disability of his left shoulder, of which he felt 10% was directly related to the July 2, 2008, injury.
Dr. Volarich also opined that the July 2, 2008, work injury "is the substantial contributing factor as well as the prevailing or primary factor causing the fraying of the biceps tendon and recurrent mild impingement that required arthroscopic biceps tenodesis and limited subacromial decompression." Dr. Volarich further opined that as a result of the July 2, 2008, injury employee sustained "30% permanent partial disability of the left upper extremity rated at the shoulder...."
We find the opinions of Drs. Hulsey and Volarich more credible than Dr. Mutchen's opinion that there was no new injury to employee's left shoulder on July 2, 2008.
Based upon the aforementioned, we find that employee met his burden of proof with respect to medical causation. We find, as did the ALJ, that as a result of the July 2, 2008, work injury, employee sustained 30% permanent partial disability of the left upper extremity rated at the shoulder.
With respect to the nature and extent of employee's permanent disability, we find that the ALJ's determination that employee is permanently and totally disabled is fully supported by the competent and substantial evidence.
Employee testified that he cannot return to work due to his numerous injuries, surgeries, and disabilities. Dr. Volarich opined that employee is permanently and totally disabled as a direct result of the work-related injuries of September 30, 2004, and July 2, 2008, in combination with each other as well as in combination with his preexisting medical
conditions that were present prior to September 30, 2004, as well as before July 2, 2008. Mr. England, the only vocational expert to provide an opinion as to employability, testified that in light of employee's medical problems, physical restrictions, physical presentation, limited daily activities, limited education, and lack of transferable skills, employee is not employable in the open labor market.
We find, based upon the totality of the evidence, that employee is permanently and totally disabled as a result of his primary injury combining with his preexisting disabilities.