Claimant, who is 37-years-old, began working for Employer in June 2014. Claimant passed a pre-employment physical before working for Employer. Before working for Employer, Claimant had no treatment or diagnostic testing with respect to his low back, and no physical restrictions.
On July 25, 2015, Claimant was working as a material handler, and was driving a tugger to deliver a 200-pound bin of brake pedals to the assembly line. Claimant unhooked the bin from the tugger, and pushed and pulled the container by the handles. While attempting to move the heavy container into position on the line, Claimant felt a pop, followed by pain in his low back.
WC-32-R1 (6-81)
Page 3
Issued by DIVISION OF WORKERS' COMPENSATION
Injury No. 15-053452
Claimant immediately told his supervisor and requested medical treatment. Claimant went to the plant medical department on July 25, 2015, and reported a sharp knotting pain across his lower back after pushing and pulling a brake pedal bin. Under objective findings Claimant was observed to be walking with a slow gait, and was slowly and deliberately moving up and down from a seated position in the chair. The assessment was lumbosacral pain. Claimant returned to the plant medical department on July 27, 2015, and reported his back continued to hurt. Under objective findings Claimant was observed to be walking slowly with an unsteady gait and walking slouched over. The assessment was back pain. Claimant was given Motrin, a cold compress, and Biofreeze to use PRN. Claimant was given a medical pass for the remainder of his shift.
Due to significant low back pain, Claimant sought treatment on his own at Anderson Hospital Emergency room on July 27, 2015. Claimant gave a history of a sudden onset of back/side pain while pulling some equipment at work. Claimant was diagnosed with a muscle strain and was prescribed medications and given a restriction of no heavy lifting.
Claimant also saw his primary care physician, Dr. Melissa Kalaher, on July 29, 2015, and reported a work injury the previous Friday while pushing/pulling, and experienced the sudden onset of low back pain. Claimant indicated he returned to work on Sunday, and his prior pain had not yet resolved when he lifted something overhead, and the pain got significantly worse. Dr. Kalaher diagnosed low back pain, prescribed medication, and took Claimant off work for two weeks.
Claimant returned to the plant medical department on July 30, 2015. Claimant again gave a history of injuring his low back on July 25, while pulling a bin full of brake pedals. Claimant was in terrible pain and his right leg felt numb. Claimant was walking very slowly, bent forward at the waist. Claimant was placed on light duty restrictions, given suggested home exercises, and a follow-up appointment was scheduled for August 17, 2015.
Claimant received a letter dated August 5, 2015, from Employer, denying his July 25, 2015 work injury. Employer opined the claim for Workers' Compensation benefits was not compensable, and it would accept no liability for any medical treatment rendered.
After Employer's denial, Claimant continued to seek medical treatment from Dr. Kalaher. Dr. Kalaher continued to prescribe pain medications, continued Claimant's work restrictions, and ordered an MRI. The MRI performed on August 19, 2015, revealed chronic bilateral L5 pars defects without spondylolisthesis, and mild lumbar and lower thoracic spondylosis. Claimant followed up with Dr. Kalaher on September 2, 2015. Claimant told Dr. Kalaher his back pain would come and go, and sitting and standing for long periods could bring it on and make it worse. He indicated he had changed his job to quality control which did not require reaching, bending, stooping, and lifting and asked to return to work. Dr. Kalaher diagnosed back pain with radiation. She allowed him to return to work with no lifting over 25 pounds.
Claimant returned to the emergency room at Anderson Hospital on September 12, 2015. Claimant was complaining of back pain. He stated his pain had worsened while at work. Claimant was diagnosed with back pain, and was given a Medrol Dosepak and work restrictions.
Claimant followed up with Dr. Kalaher on September 17, 2015, regarding the
WC-32-R1 (6-01)
Page 4
Issued by DIVISION OF WORKERS' COMPENSATION
Injury No.: 15-053452
exacerbation of his severe low back pain. Claimant was advised to use Percocet as-needed for pain, and was given a work restriction. On September 22, 2015, Dr. Kalaher assessed Claimant with low back pain and advised him to keep his return appointment with pain management to formulate a long-term plan. Claimant was advised to remain off work.
Claimant began treating with Vigilant Pain Management on October 5, 2015. Claimant gave a history of a work injury in July 2015, and complaints of low/mid back pain since. On October 13, 2015, Dr. Kalaher wrote a letter stating Claimant suffered a work place injury to the low back on July 25, 2015. She indicated Claimant had been diagnosed with low back pain and degenerative disk disease in the thoracic and lumbar spine. Dr. Kalaher indicated Claimant had been referred to a pain management specialist for further evaluation and treatment. She opined the injury he suffered while at work was the prevailing factor in his current condition.
On January 26, 2016, in the midst of his treatment for his back, Claimant underwent bariatric weight loss surgery.
Claimant followed up with Dr. Kalaher on November 1, 2016, for several complaints, including back pain. Claimant reported his job had changed and required more lifting. He reported he had no radiation to the buttocks or legs, but it went to the mid-back.
Dr. David Volarich examined Claimant