Claimant is a married father of two who graduated from high school and has worked as a farmer, equipment repairman, landscaper, parts maker, and truck driver. He has never held a sedentary job and has no useful computer skills. In 2005, he began working for Employer as a delivery driver/yard man. His duties included unloading and delivering a range of building supplies, driving trucks, waiting on customers, and cleaning up the yard. While he broke his left little toe in 1984, and was treated for ingrown toenails in 2008, Claimant had no permanent disability of the lower extremities at the beginning of 2010. In 2009, Claimant had pneumonia, but had fully recovered without ongoing symptoms by the end of the year.
On January 4, 2010, while attempting to enter a truck, Claimant's left foot slipped on a step and he experienced a "kind of stinging" in his foot. He continued to work that day and the next, but the pain level increased. When his store manager, Tom Brian, noticed Claimant limping, Claimant told him about the accident. He sought treatment on January 6, 2010 from Dr. Wieman, who had previously treated him for ingrown toenails. Dr. Wieman diagnosed a broken $4^{\text {th }}$ metatarsal, applied a hard cast, and ordered Claimant to be non-weight bearing on the left foot for an initial period of one month. Claimant filled out an accident report immediately after his first visit. At the February $1^{\text {st }}$ follow up appointment, Dr. Wieman replaced the hard cast and extended the non-weight bearing order by two weeks. Claimant began to develop shortness of breath.
On February 8, 2010, Claimant presented to St. Joseph's Hospital West with severe shortness of breath, and upon testing he was diagnosed with multiple pulmonary emboli ("PE") and admitted for anticoagulation and pulmonary consultation. He remained in the hospital until February $12^{\text {th }}$, mostly in the ICU. His hard cast was replaced with a removable cast, he used a walker, and he started on blood thinners. Claimant said his lungs were "full of clots," and he understood his condition to be life-threatening at the time. From February 12, 2010 to December 20, 2010, Claimant incurred expenses of $\ 128.53 for prescription medication related to his blood and lung conditions. ${ }^{2}$
On March 2, 2010, Claimant returned to St. Joseph's Hospital West with increased dyspnea (shortness of breath) and leg swelling. Venous duplex exam of the left lower extremity ("LLE") showed partial vein thrombosis in the left posterior tibial and peroneal veins, likely chronic. In March, Claimant's fracture healed, but his left foot remained very swollen - he could not even get a shoe on and therefore could not work. He was discharged the same day. Claimant testified "workers comp" denied liability for the charges associated with this visit, but the only evidence of charges with a March 2, 2010 date of service is a $\ 651.00 bill for Lake Forest Emergency Group LLC ${ }^{3}$.
On March 15, 2010, Claimant consulted with Dr. Schneider for symptomatic bilateral lower extremity venous stasis disease and DVT/PE. He noted, "Duplex today shows only some calf vein thrombus left leg only normal on right. The cause for this is most likely secondary to his injury at work (fracture). DVT following any lower limb injury is fairly commonplace." He
[^0]
[^0]: ${ }^{2}$ Dr. Montgomery, the prescriber for most prescriptions, was an attending physician while Claimant was first hospitalized. Other prescribers included his hematologists and primary care physician.
${ }^{3} The total bill from Lake Forest Emergency Group is \ 1,003.00, but Claimant did not substantiate the charge related to a July 1, 2010 date of service.
further found no indication for IVC filter and thought it was okay for Claimant to return to work from a vascular standpoint, subject to Dr. Wieman's approval. At this time, Claimant had difficulty breathing, his legs were swollen and he could not work.
Also in mid-March, Dr. Wieman found the fracture to be clinically healed, but Claimant had continued problems with pain and swelling due to the DVT. He could not even get a shoe on and therefore could not work as of March 15. In April, Dr. Wieman started Claimant on TED stocking for the swelling, treated him for ingrown toenails secondary to swelling, and cleared him to ambulate on his left foot. She stated he could not return to work until medically cleared by his pulmonologist. On May 12, 2010, Dr. Wieman found both the left great toenail and the metatarsal fracture were well healed, and released Claimant to full duty, noting "[h]is biggest issue continues to remain swelling." Dr. Wieman rated Claimant with 0\% permanent partial impairment of the left $4^{\text {th }}$ metatarsal/left foot. There do not appear to be any unpaid charges from Foot Care Inc. (Dr. Wieman's office) through May 12, 2011.
On May 17, 2010, Dr. Goldberg wrote: "Robert Badock has been under my care for treatment of a Pulmonary Embolism since April 15, 2010. He is on continuing Coumadin therapy for this condition. He is released to return to work, however due to his left lower extremity swelling, he should remain in a position where he would be able to sit and elevate his left leg. Also, it should be noted that while on blood thinners, like Coumadin, the patient would have an increased risk of bleeding should he receive a contusion or laceration."
While he was under Dr. Goldberg's care and because he was on blood thinners, Clamant had regular blood tests. The statement associated with Dr. Goldberg's care (Exhibit 13) indicates charges of $\ 2,205.00 between February 8, 2010 and March 22, 2011, with payments of $\ 1,872.90, adjustments of $\ 323.90, and a balance of $\ 657.00. It appears the payments were from an insurance company, not Claimant.
In mid-October, 2010, Claimant began to experience an increase of chest pain and shortness of breath that required him to be taken by ambulance to St. Joseph Hospital West, where tests found no abnormalities and ruled out recurrent PE as the cause of his chest pain. The emergency room doctors thought Claimant's worsening diastolic heart failure probably explained fluid retention. The charges associated with this admission originally totaled $\ 17,693.40, but were adjusted to $\ 10,616.04. There is an unpaid ambulance bill of $\ 762.97 in evidence. The unpaid charge from Radiological Imaging for October 18 and 20, 2010 tests is $\ 282.44. At hearing, Claimant did not remember the details of this hospital admission.
At the authorization of Employer/Insurer, Claimant came under the care of Dr. Rao of Midwest Vascular and General Surgery. It was his impression Claimant suffers from a moderate to significant post deep vein thrombosis swelling or a post phlebitis syndrome. As of his first visit on November 30, 2010, he felt Claimant was not ready to return to work. On December 28, 2010, Dr. Rao interpreted an ultra sound as showing no evidence of deep vein thrombosis in the veins of the left leg, but felt there was evidence of venous insufficiency or venous valvular insufficiency in the popliteal vein. With respect to medication and causation, Dr. Rao stated that usually, "six months to a year of anticoagulation is all patients need once the initiating factor for the blood clot has been removed. In this case, it was his injury and his cast."
On January 26, 2011, at the recommendation of Dr. Rao, Claimant consulted with Dr. John Finnie of Mercy Medical Oncology-Hematology (Mercy Cancer Care), who provided guidance regarding Claimant's history of PE and DVT. Dr. Finnie's notes indicate Claimant was very reluctant to reduce or come off of his Coumadin therapy for fear of repeat episodes of pulmonary emboli. Claimant continued to see Dr. Finnie throughout 2011 and beyond. Claimant documented $\ 799.00 in charges from Dr. Finnie's office. ${ }^{4}$
On February 15, 2011, Dr. Rao noted, "I am going to release [Claimant] back on March $1^{\text {st }}$ for two week duty of reduced activity lifting nothing heavier than 30 lbs . On March 15, 2011...I will release him for full duty with maximum medical improvement." The Disability Certificate of 2/18/11 indicates no lifting over 50 lbs for 2 weeks with RTW full duty on 3/15/2011. Employer stopped paying TTD based on this opinion.
Sometime in early 2011 at Employer's request, Claimant saw Dr. Mankowitz, a cardiologist, who opined: 1) The October 2010 hospitalization was unrelated to the injury sustained on 4 January 2010, as there was no evidence of a recurrent pulmonary embolism. The cause for the chest pain and shortness of breath ("SOB") was unclear. There was no evidence of a cardiac or lung problem...: 2) SOB is probably due to deconditioning and sleep apnea...; 3) Coumadin treatment for one year is to treat blood clots in left leg and lungs, and thus is related to work injury. Swelling in left leg is related as it is caused by the damage caused by the blood clots. Long-term treatment consists of compression stockings. SOB and sleep apnea predate and are unrelated to the injury. A follow up Chest CT with contrast should be done to assess for residual pulmonary emboli; 4) Claimant appears to be at MMI.
As of March 11, 2011, Dr. Rao thought Dr. Mankowitz's recommendation for a repeat CT is reasonable "to close the definitive documentation of pulmonary embolism in this case." He "fully expects" the CT to be negative, in which case the ongoing issue is over. Dr. Rao wrote, "The more tests that come back normal will reinforce to Claimant hat he needs to get back into the workforce and resume a normal life." As predicted, two CT scans (one with contrast, one without) were negative for pulmonary emboli. Dr. Rao provided a rating of 10-15\% permanent partial disability for the vein damage sustained from a deep vein thrombosis following the injury on January 4, 2010. There is a March 24, 2011 bill from Lincare totaling $\ 781.46 for medical equipment.
According to a June 5, 2011, follow up exam and supplemental report, Dr. Mankowitz felt Claimant no longer needed Coumadin, but could take aspirin instead. He suggested Claimant could return to work, was at maximum medical improvement, and should exercise to lose weight and improve his shortness of breath and endurance.
In July 2011, Claimant was experiencing pain in his right foot, and an x-ray on July 2 found no fracture; findings suggestive of gout with superimposed osteoarthritis or cyst. On July 6, 2011, Claimant saw Dr. Armbruster of Troy Surgical, who noted increasing right foot pain of 3 weeks duration unlike old gout with a history of DVT of his LLE and pulmonary embolus. The left leg clot occurred due to a fracture of his left metatarsal. Positive findings include moderate to severe non-pitting edema of the lower extremities, tenderness of right foot at base of toes at mid foot. On February 20, 2012, Claimant saw Dr. Armbruster in follow up visit for
[^0]
[^0]: ${ }^{4} Of the \ 799, Claimant provided evidence $\ 645 was paid by Employer/Insurer. There is no evidence the balance is unpaid.
cellulitis and a staph infection for which he was hospitalized over a few days. At that time, the diagnoses included apnea, DVT, GERD and benign prostatic hyperplasia. ${ }^{5}$
On August 10, 2011 and February 16, 2012, Claimant saw Dr. Wieman for recurrent ingrown toe nails of both large toes. She thought the left foot was swollen because of previous injuries. She thought the right foot is swelling because he is overcompensating and doing more on his right foot. He cannot wear shoes. The charges for such treatment total $\ 300.00
When Claimant was seen for outpatient follow up at Dr. Finnie's office on March 20, 2012, he had developed gout in his right foot. The doctor noted, "It does appear that due to the patient's difficulty now involving his right foot, that he would not be eligible to continue to work. He does appear to be a good candidate for disability." There is a bill of $\ 897.62 from Mercy Hospital St. Louis for outpatient services from March 20, 2012 to April 18, 2012, which corresponds with his chart from Dr. Finnie.
On April 5, 2012, Claimant's primary care physician, Dr. Armbruster, noted patient presents for "disability papers." Complaints include decreased energy, anxiety, and chest pain due to pleural problems, cough, depression, fatigue and headache. Also, myalgia, indigestion, joint pains, pain, rash on legs, both feet hurt; pain averages 7; SOB w/ stairs and carrying 50 lbs for a few feet; left LE is atrophic, straight leg raising positive.
On May 7, 2012, Claimant saw Dr. Goldberg for evaluation of wheezing and postphlebitic syndrome. Dr. Goldberg wrote, "I suspect he can only return to work if he can be in a seated position such that he can keep his leg elevated." Recommendations include lifelong Coumadin and "wear support stockings as able and keep LLE elevated as much as possible." On August 20, 2015, Dr. Goldberg reiterated, noting Claimant "is here today to discuss worker's comp related to post phlebitis syndrome LLE. In the past I and other physicians have recommended to keep legs elevated as much as possible. This recommendation remains unchanged....Needs to keep LLE elevated as much as possible. The only appropriate vocation would be a desk job."
Like Dr. Goldberg, Dr. Wieman addressed Claimant's work-related disability. In her June 8, 2012 letter, Claimant's treating foot doctor wrote:
This [is] a letter to address the current limitation of [Claimant] regarding his feet. He sustained an injury at work on $1 / 4 / 10 to his left 4^{\text {th }}$ metatarsal which was treated with cast immobilization. During his treatment he developed a DVT leading to a pulmonary embolism for which he was hospitalized. Since that time he has had bilateral lower extremity pitting edema, leading to chronic ingrown toe nails and the inability to wear normal shoe gear. Because of this he cannot be on his feet for long periods of time. He has had multiple procedures for ingrown toe nails because of his edema... and continues to have lower extremity edema even with the use of compression stockings.
In a July 19, 2012 letter, she wrote a letter concerning Claimant's "right foot pain and limitations which dates back to 2004 for which he has been treated for gout and hallux limitus." She noted
[^0]
[^0]: ${ }^{5} Dr. Armbruster's charges included \ 160 for the 7/06/2011 visit for right foot pain; $\ 150 for eye infection on 10/7/2011; and $\ 195 for a 2/20/2012 follow up visit after a hospitalization for cellulitis. There is insufficient evidence connecting these charges with the work accident.
progression of osteoarthritis in multiple locations and pain with ambulation, inability to normally bend big toe, and swelling. This joint damage is permanent. These comments were made regarding Claimant's right foot, not the left foot injured in the work accident.
Dr. Volarich reviewed records, examined Claimant, and issued his first report on March 28, 2012. He diagnosed the following conditions: 1 . Left non-displaced proximal $4^{\text {th }}$ metatarsal fracture; 2. Left lower extremity deep vein thrombosis secondary to cast immobilization to treat left foot fracture causing pulmonary emboli and left lower extremity post phlebitic syndrome; and 3) Chest discomfort and shortness of breath with exertion. His ratings of disability were 15 % PPD at 110 level of the left foot for the fracture, 30 % PPD of the left lower extremity at the 160 week level, due to the deep vein thrombosis and resultant post phlebitic syndrome, and 10 % PPD of the body as a whole at the chest. He found the combination of his disabilities creates a substantially great disability than the simple sum or total of each separate injury/illness, and a loading factor should be added. In a subsequent report dated October17, 2013, after reviewing Mr. England's vocational assessment and social security administration award, Dr. Volarich wrote, "it is my opinion that [Claimant] is permanently and totally disabled as a direct result of the work injury of $1 / 4 / 10$ standing alone..."
The vocational expert, Mr. England, saw Claimant on or about May 6, 2013, reviewed records and opinions in the case and issued a report evaluating Claimant's vocational abilities. He found if he considered Dr. Mankowitz's outlook, Claimant could work. Assuming findings of other doctors, he would be much more limited. If one assumes that he needs to sit through the day with his leg elevated, Mr. England did not believe he is competitively employable. Certainly considering the restrictions noted by several of his treating doctors, it does not appear that he would be able to successfully compete for or sustain any type of work activity in the open labor market. Absent continued improvement in his ability to be up on his feet and to sit without his leg elevated through most of the day, he felt Claimant is likely to remain totally disabled from a vocational standpoint. Mr. England's opinion was unchanged on June 2, 2014 after reading Claimant's deposition and considering the social security award.
At his deposition, Mr. England summarized the medical opinions concerning Claimant's work limitations:
Dr. Goldberg thought he could work only if he were able to do a sedentary job with his leg elevated. Dr. Finney indicated that he thought [Claimant] would be a good candidate for disability because of the issues with his right foot. Dr. Volarich recommended avoiding repetitive stooping, squatting, crawling, kneeling, pivoting, climbing, impact maneuvers....Dr. Armbruster, who's his primary care physician filled out a form saying he thought he could sit for an hour in an eight hour day, could stand, walk and work a half an hour each in an eight hour day, [with some lifting restrictions].
Mr. England made further references to Dr. Armbruster's observations that standing or walking aggravated symptoms while elevating the leg was helpful, and to Dr. Wieman's note Claimant had "problems with ambulation on a continuous daily basis." Although Dr. Mankowitz's restriction would allow Claimant to return to full duty, he is "much more limited" by the other doctors' restrictions. Mr. England noted Claimant's lack of skills for sit-down jobs and testified "if he really does have to sit with his leg elevated most of the day...I don't believe that he's going to be able to go out and compete and sustain any kind of work...in the open labor market."
On cross examination, Mr. England made some concessions. He acknowledged other doctors besides Dr. Mankowitz released Claimant to full duty. But more importantly, Mr. England acknowledged his opinion is built on the truth of the proposition that Claimant "is off his feet most of the day with his leg elevated" up to the level of his heart. Yet, if he assumed Claimant was more active, could sit for 30 minutes at a time and just needs to get up and walk, then it is "probably true" Claimant is competitively employable in positions such as security work or parking lot attendant.
Claimant testified to his limitations. He continues to have severe swelling in both his right and left legs. He continues to have pain in his legs. This affects his ability to do things during the day, it affects his sleep, and it affects every area of his daily life. Claimant tries to live as normal of a life as he can. He helps with his children's rabbits by feeding them, he attempts to do general housework but at his own pace, and he has attempted to assist others with small tasks. He does drive but must take breaks. All of these activities cause him pain and swelling.
Although Claimant can check his email on a computer, he does not know how to use Word, Excel or PowerPoint, and cannot type fast or accurately. He has never worked at a desk nor does he have the skills required to do a desk job, at home or otherwise.
Claimant has the ability to be physically active, drive wherever he or his family needs to be, and do chores around the house. During the hearing, Claimant did not elevate his leg, but he did have to stretch his legs. He admitted he can be on his feet all day as often as once a week or two, can sit for up to 90 minutes at a time before he has to get up and stretch, and he does not sit with his legs elevated all the time. It is not necessarily easy or convenient for Claimant to raise his leg when he is out of the house.
Claimant understands Dr. Finnie and Dr. Armbruster to say he cannot work, and Dr. Goldberg said he could only do sedentary work. He continues on Warfarin/blood thinners, which requires medical checkups every three months. Claimant believes the factors which prevent him from doing any job on a normal basis are the swelling and pain in his legs and the fact he gets short of breath just walking a short distance.