Claimant is a 46 year old man who left the ninth grade to enter the workforce as a laborer/warehouseman. He worked as a laborer until 2002 or 2003, when he obtained his CDL and became a driver. He drove for several bus companies, but from approximately 2004 to May 2012, he worked solely for Employer. When Claimant started with Employer, he weighed between 375 and 400 pounds. Despite being overweight, Claimant had no problems with stamina, and his weight did not hinder his job. He "was able to do everything and in due fashion." There is conflicting evidence as to Claimant's weight on the day of the accident, but it
appears he weighed close to 500 pounds ${ }^{1}$. At hearing, Claimant weighed 520 pounds. During his employment, he passed a basic annual physical every year, and passed the rather demanding physical necessary to retain his DOT certification every other year.
Claimant operated regular school bus routes as well as charter runs for field trips and other special activities. His usual routine for each run would be to conduct a pre-trip bus inspection, drive to pick up and drop off children, conduct a post-trip inspection and clean out the bus. On October 26, 2009, Claimant was conducting an early morning pre-trip inspection when his legs slipped under the bus, his "body went the other way," and he "felt a snap and a whole lot of excruciating pain" in his right leg.
An ambulance transported Claimant to the emergency room at St. Anthony's Medical Center, where he was diagnosed with a broken tibia and fibula of the right leg. On October 27, 2009, Dr. Medler surgically repaired his ankle using "rod and nails." Claimant was in the hospital for approximately 30 days for acute therapy, and then released to Green Park Nursing Home, a rehabilitation facility, because he was non-weight bearing and could not negotiate the stairs in his home. It was while he was receiving this emergency treatment that Claimant was first diagnosed with diabetes ${ }^{2}$.
After more than three months of therapy at Green Park, he could walk and he was released in March 2010 to outpatient therapy and work hardening, where he continued to progress. By November 12, 2010, when he reached MMI, Claimant no longer needed a cane or walker, and could walk the distance required of him to do his job.
During his inpatient therapy at Green Park, in early Spring 2010, Claimant testified he started having left leg pain that he attributed to putting so much weight on his left, non-injured leg. Jason, his therapist at The Work Center, noted Claimant felt his left knee was weak and sore at several visits in April, and his monthly update reports in May, June and July 2010 contained the notation that Claimant comments on occasional pain in his left knee during tasks. In July, Dr. Medler noted, "[h]e is also reporting more pain on the left knee than the right knee and he says that sometimes it feels like it gives out on him." However, Dr. Medler dismissed the left knee symptoms as unrelated to the work injury, and never examined or treated the left knee. When he was able to treat on his own, Claimant obtained cortisone injections to his left knee, although he had significant diabetes-related complications after one injection that required emergency treatment. He currently has a recommendation for a total knee replacement.
In August 2010, Claimant returned to work for Employer performing the same general duties he did before his accident, and driving the same routes. He also passed the physically demanding DOT test in 2010, and all other physicals. However, because he did not take the activity and kindergarten routes after his return to work, he worked fewer hours. He attributed his need to cut his hours to leg pain and compromised endurance. Claimant performed all the duties of a bus driver for Employer throughout the 2010-2011 and 2011-2012 school years.
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[^0]: ${ }^{1}$ At deposition in 2014, Claimant testified he was around 490 to 500, as did both doctors. Furthermore, the home assessment conducted February 26, 2010 indicated he weighed approximately 510 lbs. However, hospital records from October 2009 indicate Claimant weighed 420.1 pounds and the discharge summary from Green Park Health Care listed a weight of 430 on March 5, 2010.
${ }^{2}$ Other than the treatment he received for diabetes at St. Anthony's and Green Park, Claimant did not have medical care for diabetes until August 2012 when he started seeing Dr. Ambercrombie, his PCP. Dr. Abercrombi noted in July 2012 that Claimant had "leftover metformin from 2009 that he never took."
In June 2012, Claimant submitted himself to the annual physical conducted by Employer. He did not pass the test because of his high blood pressure and high blood sugar. He also was diagnosed with neuropathy in August 2012, although he testified he began experiencing the symptoms of foot numbness at the end of the 2011-2012 school year. He now has numbness in his hands and feet. He never took the 2012 DOT physical because he could not pass with his high blood pressure, neuropathy and dependence on insulin, which began in August 2012. He also felt he could not jump off the bus or carry the weight the DOT required.
At the time of the hearing, Claimant complained of deep and aching pain in his right leg, mostly when it is cold and wet. The right leg is painful with weight bearing, and limits his endurance. He has trouble going up stairs, but experiences more pain going down, and usually takes stairs one step at a time. Claimant reports balance issues because of his complaints of left knee pain, in combination with his right leg pain.
With regard to his left knee, he described it as "bone on bone." He said he has locking in the knee and thinks he needs a knee replacement. He said that the more he walks, the more it hurts and swells. He said it is constantly in pain and aches all the time. He said he has arthritis in the knee. He said it also causes balance problems.
He also described problems due to his weight. He said his weight causes endurance problems and he "runs out of energy." He said his endurance now is limited to walking approximately 60 feet and it has gotten worse recently. He estimated he could stand at one time from 90 seconds to two minutes. He self-limits his lifting to 10 pounds.
Claimant described his typical day. He takes 14 different prescription medications, mostly for diabetes, high blood pressure, and cholesterol. Around the house, Claimant limits housework to dishes, vacuuming and laundry, and some light cooking, which he sits down to perform. He uses a special tool to help him get dressed and put on his socks. He generally spends the day watching TV and reading, although he gets out once or twice per week to go to doctors, the bank or the food pantry. Claimant supports himself through Social Security Disability benefits, which were awarded retroactive to May 2012, and food stamps. He gets help from friends and family members. Claimant no longer enjoys hobbies such as fishing, attending sporting events and going to rock concerts.
Dr. David Volarich examined Claimant, issued a report, and testified by deposition. He diagnosed right tibia, fibula fracture status post placement of a tibial intramedullary nail with retained hardware. He also diagnosed left knee pain syndrome secondary to abnormal weight bearing. The left knee pain was due to patellofemoral syndrome from abnormal weight bearing. He did not find anything wrong with the right knee (no crepitus or evidence of derangement), while the left knee had significant crepitus. The work accident of October 26, 2009 was the prevailing factor in causing diagnoses. The disability ratings he assigned were 45 % PPD of the right lower extremity due to the fracture, and 35 % PPD of the left knee due to the patellofemoral syndrome.
The only preexisting disability Dr. Volarich found was morbid obesity, which has not changed significantly since the accident. He rated the disability at 35 % PPD of the body as a whole due to difficulties with agility, endurance and shortness of breath, and found the obesity to be a hindrance to employment. Dr. Voalrich recommended Claimant pursue a weight loss
program and consider bariatric surgery, because weight loss would have a positive impact on several of his problems. Furthermore, Dr. Voalrich acknowledged there is no medical reason Claimant could not lose weight, and because of the possibility he could lose weight with bariatric surgery, his obesity is not permanent. He further found the combination of injuries to be greater than the simple sum.
Regarding his diabetes and its combination with the work injury, Dr. Volarich specifically testified, "I don't think he really had a problem from the diabetes." Dr. Volarich testified it got worse after Claimant was released at MMI from the work injury, specifically in August of 2012. He did not rate diabetes as a preexisting condition or disability, and did not relate it or his obesity in whole or in part to his work injury.
Dr. Volarich did not make the assessment that Claimant was permanently and totally disabled. Furthermore, he did not testify in his deposition to any need for future medical treatment related to the work injury. In his report, Dr. Volarich wrote surgery is not indicated as of the exam, although if the hardware were to fail or otherwise become painful, the need to perform additional surgeries could arise. "In order to maintain his current state," Dr. Volarich recommended ongoing conservative care for his pain syndrome ${ }^{3}$. The final recommendation was for Claimant to follow up with his personal physician for any additional medical care required in the future, including consideration of a weight loss program and possible bariatric surgery.
Dr. Robert Medler, the treating surgeon, testified on Employer's behalf. Dr. Medler described how he surgically repaired Claimant's leg, followed him postoperatively in the hospital while Claimant was concurrently treated for high blood pressure and previously undiagnosed diabetes, and discharged Claimant to a rehab center because he lacked the independence to go home. Claimant demonstrated progress during follow up office visits, although he still had right leg pain, and in July 2010, also complained of left knee pain. Dr. Medler did not think the left knee pain was related to the right leg injury because he did not make left knee complaints immediately after the accident. By September 2010, Claimant reported he had passed his DOT physical and was back at work.
As of November 12, 2010, Dr. Medler placed Claimant at MMI with a diagnosis of healed tibia fracture. His incisions were well healed, his x-rays looked 95 % healed, and there was no significant swelling. However, Claimant did make complaints of daily pain. Dr. Medler assigned PPD of 5 % of the leg below the knee, and felt with a reasonable degree of medical certainty that no additional medical treatment was necessary.
Regarding the left knee complaints, Dr. Medler did not think Claimant's abnormal weight bearing from favoring his right leg would cause internal derangement or patellofemoral syndrome. On cross exam, he conceded Claimant could be experiencing some pain from putting more weight on his left leg while recovering from the fracture in the right, but such complaints get "sorted...out" with the resumption of normal gait. There is no damage to the joint from extra walking.
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[^0]: 3" Including but not limited to narcotics and non-narcotic medications (NSAID's), muscle relaxants, physical therapy, and similar treatments as directed by the current standard of medical practice for symptomatic relief of his complaints." He also recommended Glucosamine supplements.