The administrative law judge (ALJ) erred in finding that employee's thoracic outlet syndrome (TOS) did not arise out of and in the course of her employment.
The parties stipulated that occupational disease (OD) culminated in disability on June 23, 2016. The employer accepted the compensability of the employee's bilateral tendinitis but denied her claim for disability related to TOS.
Four physicians offered their opinions on the issue of medical causation. The employer offered the opinions of Dr. Dennis Estep and Dr. Jeffrey Woodward. Dr. Estep is board certified in OD, but his resume indicated no specialized training in TOS evaluation and treatment. Dr. Woodward specializes in physical medicine and rehabilitation. His listed supplemental medical training appears limited to the treatment of the back.
Dr. Woodward also lacks specialized education or training in the evaluation of TOS.
In contrast to employer's experts' generalized qualifications, employee's medical expert Dr. Robert Thompson is an attending surgeon at Barnes-Jewish St. Peters Hospital and has been Director of the Multidisciplinary Center for Thoracic Outlet Syndrome since 2006. Dr. Thompson co-edited a textbook on TOS and has authored numerous chapters in other vascular and surgical textbooks on TOS. He has either lectured or provided presentations as a TOS expert over fifty times. For the last five years, Dr. Thompson has limited his medical practice to the evaluation and treatment of TOS. Dr. Thompson is a nationally recognized TOS expert.
Dr. Estep referred the employee to Dr. Thompson. As confirmed by Exhibit $3^{1}$ to his deposition, Dr. Thompson reviewed Dr. Estep's treatment records before authoring his narrative report. Although Dr. Thompson did not specifically recall reviewing these medical records when initially cross-examined, he later confirmed his review of the employee's past medical records.
Dr. Thompson did not ignore other doctors' opinions. Nor was he dismissive of other physicians' opinions by stating that he did not know the details or expertise of those who rendered them and considered his knowledge and training in evaluation and treating patients with TOS more significant.
Dr. Brent Koprivica is board-certified in occupational medicine and a member of the American Academy of Disability Evaluating Physicians. He is a recognized expert in evaluating causation, impairment, and disability under The Workers' Compensation Law. The fact Dr. Thompson and Dr. Koprivica were both subject to cross-examination during their depositions also enhances their credibility.
Dr. Thompson and his team initially saw the employee on April 5, 2017. She gave a history of doing office-based work and developing weakness, numbness, and tingling in both hands. The employee had also developed intermittent bluish discoloration in the arms and hands.
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[^0]: ${ }^{1}$ Transcript, p. 418.
Dr. Thompson performed a physical examination, which, along with the employee's history of the onset of symptoms, led to his clinical diagnosis of neurogenic thoracic outlet syndrome. The employee met ten out of the fourteen published and validated clinical diagnostic criteria for neurogenic TOC syndrome in five categories, making a solid diagnosis. Dr. Thompson concluded,
It was my impression at that time that her current condition of neurogenic TOS was severely disabling, as reflected by history, description of symptoms, physical examination, and DASH score. I felt she was unable to work in her usual job due to the limitations and restrictions as a result of this condition. ${ }^{2}$
Dr. Thompson recommended a course of physical therapy directed toward TOS. He instructed the employee to continue taking NSAIDs for pain as needed. Dr. Thompson also recommended that the employee undergo an imaging-guided right anterior scalene and pectoralis minor muscle block with a local anesthetic to provide further information. The test resulted in ". . . substantial but temporary improvement in symptoms and was considered a positive block. This strongly confirmed the clinical diagnosis of neurogenic TOS . . ."3
When specifically asked about any causative relationship between employee's job duties for the employer and the development of neurogenic TOS, Dr. Thompson opined, "The symptoms and physical examination findings attributable to neurogenic TOS that she exhibited [on April 5, 2017] had started in 2016, when she was working for EGS as a customer service representative, in the absence of another specific injury, incident, or event, her work involved repetitive strain activity with both upper extremities that aggravated her symptoms and over time these symptoms progressed to limit her work activities. It is my opinion that her development of bilateral neurogenic thoracic outlet syndrome was directly and causally related to the work activities that Ms. Holland conducted while employed at EBS and that there activities were the primary or prevailing factor in her development of this condition [emphasis added]." ${ }^{4}$
After reviewing all relevant past medical records and taking an extensive history of the employee's past work and job duties for the employer, Dr. Koprivica gave a similar opinion on causation. He opined that positioning her shoulders forward and repetitively using them with her arm away from the torso was sufficient to narrow the thoracic outlet. Dr. Koprivica concluded that the type of job duties the employee performed was sufficient to produce her injury. The employee did not do this type of repetitive activity at home. The general public does not use upper extremities to the same extent as the employee's employment required. Dr. Koprivica stated, "Ms. Holland's described upper extremity use activities, in terms of the postures in doing her data entry tasks as well as the repetitiveness of those activities, are felt to represent the direct, proximate and
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[^0]: ${ }^{2} Transcript, p. 410.
{ }^{3} Id., 410-411.
{ }^{4}$ Id., p. 416, see also pp. 324-325.
Improve: Kimberly Zachary Holland
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prevailing factor in the development of disabling bilateral neurogenic thoracic outlet syndromes.5
Employer's experts Dr. Estep and Dr. Woodward fail to correctly diagnose the employee's condition. Dr. Estep referred to the employee's condition as vascular TOS rather than neurogenic TOC. Dr. Woodward had no diagnosis for many of the employee's symptoms. Neither Dr. Estep nor Dr. Woodward mentioned whether either performed any nationally recognized clinical tests related to TOS. Dr. Estep found that TOS is based on "an anatomic variation" but gave no rationale for this opinion.6
Dr. Thompson testified certain conditions, such as the presence of a first cervical rib, make people more susceptible to TOS development but acknowledged that these variations are present in probably seventy to eighty percent of the population at large and are not causative.
Dr. Woodward seemed unsure of any diagnosis other than extensor tendonopathy. He referred to coldness and color changes in the employee's hands present at the time of her office visit when she had not been doing repetitive hand activities, which he felt made the diagnosis of "vascular thoracic outlet syndrome [emphasis added]" unlikely.7
Intermittent color changes in employee's bilateral forearms were also present in April 2017 when Dr. Thompson first evaluated the employee. Dr. Thompson found no evidence of arterial or venous forms of TOS but instead found "sympathetic-mediated vasospasm related to nerve irritation that explained the bilateral finger discoloration."8
Further, by the time Dr. Woodward evaluated the employee's condition, the changes in the nerves and fibers of the muscle had already occurred. Therefore, symptoms would be present due to these chronic changes even without performing the employee's injurious job duties.
The ALJ based his decision largely on the belief that the employee's symptoms must have started before her work for the employer. He stated, "The Claimant testified that she made certain ADA accommodation requests related to her alleged occupational disease one month after starting her employment. This represents compelling evidence that her symptoms began well prior to commencement of her employment at EGS."9 Whether the employee may have been exposed to repetitive motion in earlier employment is irrelevant. The parties stipulated that the employee was exposed to repetitive trauma in her work for the employer from February 2015 to June 23, 2016, a period of sixteen months. The provisions of § 287.067.8, proving for liability of the immediate prior employer where exposure which is found to be the cause of the injury is for a period of fewer than three months, therefore do not apply.
5 Id., p. 203.
6 Transcript, 461.
7 Id., 452.
8 Id., 410.
9 Award, p. 14.
More importantly, there is no testimony from any medical expert that the employee's TOS resulted from work at either of her two prior call center jobs. Simply because employee's symptoms began after approximately one month of employment does not alone-without other supporting evidence-lead to the conclusion that prior work duties are the prevailing factor in her development of TOS. The "exposure time" necessary for TOS development is not a matter of common knowledge but takes expert testimony. "Medical causation, which is not within common knowledge or experience, must be established by scientific or medical evidence showing the relationship between the complaint of condition and the asserted cause." Malam v. Department of Corrections, 492 S.W.3d 926,929 (2016), quoting Gordon v. City of Ellisville, 268 S.W.3d 454,461 (Mo. App. 2008).
Neither the ALJ nor the Commission may base findings on conjecture or their personal opinion unsupported by sufficient competent evidence. Gordon v. City of Ellisville, 268 S.W.3d 454,461 (Mo. App. 2008).
Employee's work for the employer had approximately five times more keyboard and mouse work than her previous call center jobs. Moreover, at the two prior call centers employee was not required to work with a defective keyboard and mouse, which required her to strike the keys forcefully-sometimes multiple times-to have them register.
Employer/insurer's Exhibit G, purports to be employer's Report of Injury. The unsigned injury report form, dated July 15, 2016, lists its preparer as "Michelle Sllvestre, Leaves Administration Analyst." The report cited employee's alleged reference to employee's delay in meeting her request for a