Claimant is a 58 year old woman who earned her BA from Harris Stowe State College, and two Master's Degrees from Washington University and St. Louis University, respectively. Claimant's first job teaching math began in 1980 with St. Louis Job Corps. In 1983, Claimant went to work for Employer, where she continued to work as a teacher until her retirement in December 2012.
Claimant had two significant injuries prior to 2010. In 1998, she injured her neck in a motor vehicle accident. Claimant testified she was offered surgery, but chose conservative treatment including physical therapy that was effective in resolving her neck pain. In March 2006, Claimant was at work when she fell on crumbling steps. She put out her right hand to break her fall, and hurt her right arm, neck and hip. As a result of the 2006 fall, Claimant experienced burning, throbbing pain in her right arm. She treated with Dr. Roy Jerome Williams ${ }^{2}$, her personal physician, who diagnosed right cervical radiculopathy and ordered physical therapy. The pain, according to Claimant's testimony, went away, although she settled the workers' compensation claim flowing from the March 2006 injury for 5\% PPD of the whole body referable to the neck and 5 % PPD of the right hip.
There are no records prior to 2007 in evidence, although the physical therapy records confirm a history of neck pain dating back to the 1998 MVA, and the problems with the right shoulder and neck following the 2006 fall. Claimant's rating doctor, Dr. David Volarich, noted that a cervical MRI from May 18, 2006 ordered by Dr. Doll showed advanced degenerative disc disease at C4-5, C5-6, and C6-7 with spondylotic spurs and dorsal projecting bony spurs which abutted the chord. Dr. William's handwritten records mention ongoing or resolving symptoms of the neck, right upper extremity, flank and/or back pain in 11 of the 15 entries between 2007 and the date of injury. The prior problems in the neck and right shoulder seemed to wax and wane, but improved with treatment.
On Wednesday, September 15, 2010, around 10:00 in the morning, Claimant was standing at the whiteboard in the front of the room instructing the class. She stood with her arm raised, writing on the board, with her head slightly turned. Suddenly, she felt something strike her on the right side of her head, above her glasses. Startled, she turned her head quickly towards in the direction of the projectile, and her body followed. She did not fall, trip or stumble. Claimant felt immediate radiating neck pain. Her head also hurt.
Upon inspection, Claimant discovered she had been struck by a ping pong ball-sized wad of crumpled paper wrapped around sunflower seed hulls. She confronted the person whose name was written on the paper, and although he denied having thrown the paper, Claimant sent a request to have the student removed from the classroom. Claimant felt violated, upset, and angry. She reported the incident and saw the nurse after class. She noted mild redness and swelling at the sight of the blow, but noted no break in skin or bruising. She could not finish the day, and went home, where she completed an incident report and called for a doctor's appointment.
[^0]
[^0]: ${ }^{2}$ Although the earliest entry in Dr. Williams' records (Exhibit 3a-d) is April 30, 2007, the Rehabilitation Institute records indicate Dr. Williams was directing her care as early as July 2006.
When Claimant saw Dr. Williams on September 17, 2010, she reported the development of headache and "exacerbation of [right] cervical radicular pain." Reduced right shoulder range of motion and right grip strength was noted. He recommended no weight overhead.
On October 5, 2010, at Employer's direction, Claimant presented at BarnesCare with complaints of headache, right sided neck pain radiating into the arm, numbness of all fingers and right hand weakness. The site of the blow was tender, but no swelling, discoloration or skin change was noted in the right forehead region. Based on her physical examination and Claimant's history, Dr. Shockley concluded the neck and right upper extremity complaints were not consistent with a blow to the forehead. Dr. Shockley also gave a credible and detailed explanation of why she thought the headaches were also unrelated, but she nevertheless recommended a head CT for a definitive evaluation ${ }^{3}$. Claimant was to seek treatment with her personal physician.
Dr. Williams referred Claimant to The Rehabilitation Institute of St. Louis for physical therapy that was temporarily beneficial, according to Claimant. An MRI taken October 21, 2010 revealed "advanced degenerative disc disease at C5-C6 and C6-C7 resulting in predominantly left neural foraminal stenosis at each level, more pronounced at C6-C7."
Dr. Todd Stewart, a neurosurgeon, evaluated Claimant on November 1, 2010. He identified problems primarily with the shoulder, finding some weakness and limited range of motion, but also noted multilevel cervical degenerative disk disease or spondylosis. He did not think her neck was the primary problem, and recommended therapy and perhaps injections to the shoulder. He attributed the shoulder symptoms to inherent right shoulder disease.
In late 2010, Claimant began treatment with Dr. Heidi Prather, a physiatrist, who diagnosed right shoulder pain and scapulothoracic dyskinesis, and treated Claimant for neck, parascapular, right upper quadrant and low back pain. Objective tests showed no rotator cuff tear, cervical radiculopathy or neuropathies. Dr. Prather noted Claimant had intermittent flares in her symptoms. Claimant reported varying degrees of relief from physical therapy, massage therapy, injections and medication.
Between Dr. Williams and Dr. Prather, Claimant had restrictions that prohibited her from working through July 18, 2011. When Claimant returned to work for the 2011-2012 school year, she required several accommodations to avoid raising her arm to write on the whiteboard. She is now retired.
On August 23, 2012, Claimant submitted to an IME with Dr. David Volarich, who took a history consistent with Claimant's testimony at hearing, conducted an exam that yielded several objective findings, and testified by deposition based on his report. Regarding the primary injury, he diagnosed "cervical right upper extremity radicular syndrome secondary to aggravation of degenerative disc disease, degenerative joint disease, and disc bulges at C4-5, C5-6, C6-7, S/P non operative treatment [and] right shoulder bursitis with mild rotator cuff tendonitis." Dr. Volarich testified the work injury of being struck on the forehead by a packet of sunflower seeds
[^0]
[^0]: ${ }^{3}$ It appears the CT was not carried out.
thrown by a student with her startled response ${ }^{4}$ was the prevailing factor causing her symptoms and need for treatment. He thought she was temporarily totally disabled through June 2011, and the charges for her treatment were reasonable and necessary.
Dr. Volarich emphasized Claimant permanently aggravated her preexisting symptoms or difficulties, and did not exacerbate symptoms that then returned to baseline. He assigned PPD of 20 % of the body for the cervical spine and 20 % of the right shoulder.
On January 11, 2013, Dr. Bernard Randolph performed a physical exam, took a complete history, reviewed relevant records and issued a report. He testified by deposition on August 14, 2013. He concluded Claimant sustained a minor contusion to the forehead on September 15, 2010, but did not sustain any structural injury to the head or neck. Nor did she aggravate or affect the natural disease process of the underlying condition of severe multilevel degenerative cervical disc disease with foraminal narrowing. He described the natural process of severe arthritic change as one that waxes and wanes symptomatically, and could not connect the current symptoms to the event.
As for the shoulder, the mechanism of injury would not produce rotator cuff tendonitis or bursitis. Therefore, Dr. Randolph did not think the treatments for rotator cuff tendonitis or scapulothoracic dyskinesia were related to the incident of September 2010. Dr. Randolph placed Claimant at MMI for the head contusion sustained on the date of injury, found no additional workup or treatment necessary, and rated her disability at 0 %.
Claimant currently complains of periodic neck pain, burning, throbbing, and numbness which radiates down the right arm. The shoulder pops, and the pain is stabbing or grinding. Claimant must take medication to lessen the pain, uses compresses and exercises. She has limited strength and motion, wakes during the night in pain, and has given up several hobbies because of her neck and shoulder.