On January 24, 2019, Claimant testified that he and another co-worker were making a delivery to a residence in Johnson County, Kansas. He and his co-worker were unloading windows and doors and in the process of placing them inside a garage at the new home when he was struck in his neck and back by a 30-foot extension ladder. Claimant testified that he had his back turned and no advance warning that the ladder was going to strike him. Claimant experienced the immediate onset of symptoms in his neck and upper back region and notified his employer of the injury immediately.
Claimant requested medical treatment. Claimant was directed to Meritas Health Occupational Medicine on January 24, 2019, the same day as the incident. Claimant presented with complaints of pain and tenderness in the area where the ladder struck him and radiating pain across his shoulder blades. The physicians at Meritas evaluated Claimant and diagnosed him with a contusion of the back wall of thorax and neck pain. He was advised to ice his back for 20 minutes two to four times per day and to take over-the-counter Tylenol or ibuprofen for pain. He was to follow up the next day.
Claimant followed up with Meritas Health Occupational Medicine on January 25, 2019. Claimant continued to complain of diffuse soreness to his back and in his trapezius. Claimant was to alternate ice or heat for 20 minutes two to four times a day to the affected areas. Claimant was to continue over-the-counter Aleve, ibuprofen, or Tylenol for pain. Claimant was prescribed Cyclobenzaprine and was to follow up in three days.
WC-32-R1 (6-81)
Page 4
Issued by DIVISION OF WORKERS' COMPENSATION
Employee: John Owings
Injury No. 19-008721
Claimant followed up with Meritas Heath Occupational Medicine on January 28, 2019. Claimant had continued right upper back pain and soreness in his neck. It is important to note that the medical records state that Claimant described a large "knot" in his right upper back at this follow-up visit, which was just four (4) days post-injury. Claimant also complained of numbness into his right hand and fingers. Claimant was referred to physical therapy three times a week for one week. An MRI of the cervical spine was ordered.
On January 29, 2019, Claimant underwent an MRI of the cervical spine that revealed a broad based disc protrusion with a small focal area left lateral herniation causing moderate left neuroforaminal stenosis at C3-4, mild central canal stenosis and degenerative changes at C4-5, C5-6 and C6-7 with mild central canal stenosis at C4-5 and C5-6.
Claimant followed up again on February 04, 2019 with Meritas. The medical records again record that Claimant complained of a large "knot" in his upper right back as well as numbness into his right hand and fingers. Claimant began a second round of physical therapy at Boost Physical Therapy on February 6, 2019.
On March 15, 2019, Dr. Brown at Meritas was concerned about the amount of soreness that Claimant was continuing to experience in his rhomboid and thoracic regions and an MRI of the thoracic spine was ordered. It is also noted that Dr. Brown considered a referral to physiatry or orthopedics during the March 15, 2019 office visit, but this was never authorized. Due to continued thoracic pain, Claimant underwent an MRI of the thoracic spine on March 20, 2019. The MRI revealed a small midline disc protrusion at T4-5 resulting in mild central canal stenosis without mass effect on the thoracic spinal cord or neuroforaminal narrowing, broad-based midline disc protrusion at T6-7 resulting in mild central canal stenosis in slight relative flattening of the ventral surface of the thoracic spinal cord, and a mild right paracentral disk osteophyte formation at T3-4 resulting in mild narrowing of the medial portion of the right neural foramen.
Claimant began work conditioning at SERC Physical Therapy on March 28, 2019. After five visits, Dr. Brown released him to full duty on April 5, 2019.
Claimant's current complaints
Claimant described continued ongoing complaints related to his back and neck injury. Claimant's largest concern was the "knot" located beside his right shoulder blade on the right upper portion of his back. The Meritas medical records make multiple references to Claimant's "knot" dating back to the original injury, but further evaluation and treatment, such as sonogram or other imaging, was never ordered or performed by Dr. Brown or the Meritas staff. Claimant states that the "knot" is visible to this day and has not decreased in size or lessened in intensity. Claimant described that his right shoulder blade will rub on the "knot" each time he moves his right arm. Any jarring or bumps cause pain. Claimant has continued muscle spasms and radiating pain across his shoulders. Claimant has difficulty sleeping due to back and right shoulder pain particularly around the region of the "knot." Claimant testified that he pursued a dispatch position because it is less strenuous than his current driver position. Claimant takes Tylenol and Advil but is able to cont