Plaintiff’s Name: Mr. ABC

Date of Injury: 10/24/2010

Date of Birth: 09/12/1969

Social Security No.: xxx-xx-xxx

Regarding: ABC vs. XYZ Corporation



Applicant’s full legal name is Mr. ABC. Mr. X represents Insurance Company that insured XYZ Corporation. Applicant already had one deposition taken before for marital i.e. divorce from the second wife. Applicant did not take alcohol or drugs in last 24 hours. He lives in one story apartment. First marriage lasted for 6 years and he has one boy who is 6 years old. The applicant attended high school and college at University College. He is the owner of performance training club named as ‘The Fitness Centre”. He played baseball, football, and basketball in high school and his injuries of high school got resolved completely. He had a right hand 4th metacarpal fracture in 1999. Had left hamstring injury in college.

There was a period of time applicant decide that he was not going to pursue any more try-outs as he was not physically capable enough due to injuries and pain. In October 2011, he had wear and tear mainly in the right hip.

He had severe right ankle sprain in 2008. He had left shoulder dislocation in 2009 and had right shoulder injury too. He was diagnosed with a concussion in 2010 when he was playing a game. He lost consciousness. He did not recall concussion he had in 2007. He has vitamin D deficiency.

He filed worker’s compensation claim in late 2012. Has stiffness in shoulders and neck. Right finger dislocation not healed properly. He has left hand, soreness in knees and pain in hip every day with stiffness and tightness in ankles. He is not able to sleep for long period of time as it is hard for him to sleep on right hip and left shoulder. So he has to do a little bit of tossing and turning at night and the pain wakes him up at night twice. He had right tibia injury in 2008.

MEDICAL RECORDS (Radiology Report at Regional MRI Centre)

Impression: Grade 1-2 strain of flexor hallucis longus tendon. Grade 1 strain of extensor digitorum longus. There was a chronic type of tear involving anterior talofibular ligament. Ankle joint effusion with focal disruption of the posterior capsule along the lateral aspect of the ankle where there is an outpouching of effusion. Approximately 2mm subchondral cyst involving central longus tendon


Impression: No indication of acute bone fracture, minor increased signal of the central talus is either mild bone contusion or unusual fatty marrow. Grade 1 to at most 2 strain involving deep fibers of deltoid ligament in the area of the anterior aspect of the posterior tibiotalar ligament was detected. Fluid surrounding flexor hallucis longus tendon, both at the foot and posterior to ankle was consistent with tenosynovitis. Minimal fluid around tibialis posterior tendon and flexor digitorum longus tendons may be physiologic or minor tenosynovitis.


Impression: Interval increase in ankle joint effusion. No loose bodies of sufficient size. A new area of marrow edema with an overlying periosteal reaction involving the posterior aspect of the distal tibia was mentioned. There was a poorer definition of the deltoid ligament. Partial injury. No edema at this time. Ligament felt to be stable. There was a significant decrease in the fluid surrounding flexor hallucis longus tendon. Some minimal fluid surrounding tibialis posterior tendon and flexor digitorum longus tendons above ankle joint reflected the minor tenosynovitis.


History and Physical by Dr. XYZ, MD at Hospital

Patient admitted following a concussion. Had no LOC but had altered sensorium lasting for a prolonged time. Had episodes of nausea and vomiting. At the time of admission had much-improved sensorium, still having nausea and vertigo when assuming an upright position and some generalized headache. He had no previous concussion. He was admitted for observation and MRI brain. He is a non-smoker and non-drinker. Currently alert and oriented. Negative Romberg sign. He had a full range of eye motion. Slightly tender posterior cervical muscles bilaterally. There was a contusion on left lower lip and abrasion on the chest. Cranial nerves were intact.

Diagnosed with grade 2 concussion


Radiology Report at Regional MRI Centre

MRI right ankle

Impression: Area of marrow edema involving posterior lateral tibia near syndesmosis has resolved. A low-density change reflecting periosteal reaction and fibrosis indicative of healing has remained. Only a minor area of linear increased signal remains on STIR images. No remaining acute abnormality is suspected. There was an interval decrease in ankle joint effusion and small posterior subtalar joint effusion. There was also an evidence of an old healed injury of the deltoid ligament. No new abnormality was seen. Minimal fluid around tibialis posterior and flexor digitorum longus tendons reflected a minor change of tenosynovitis, stable. A small amount of fluid surrounding flexor hallucis longus tendon probably relates to joint effusion. Post surgical changes at the base of 5th metatarsal.


Laboratory Report at LAB CENTRE

MCH 31.9 pg (28.0-31.0 pg), Neutrophills 32.8 % and lymphocytes 55.0% (19.0-48.0%). Creatinine 1.6 mg/dl (0.5-1.4 mg/dl) and glucose 60 mg/dl (70-110 mg/dl). Cholesterol 232 mg/dl (130-200 mg/dl) and HDL 84 mg/dl Electrocardiogram showed sinus bradycardia.


Radiology Report at Regional MRI Centre

MRI left shoulder:

History: Shoulder injury sustained during a game. Left shoulder pain. Diagnosis of AC dislocation.

Impression: Acute/subacute grade 2 AC dislocation with severe partial thickness or full thickness tear through coracoclavicular ligaments. Grade 2 strain/tear of proximal deltoid muscle at the anterior margin of acromial process. Partial interstitial tearing of a superior portion of trapezius muscle consistent with grade 1 strain. Probable small non-displaced SLAP lesion, may be chronic. Suspected tear through a peripheral portion of the posterior labrum.

MRI right shoulder:

History: Right shoulder pain.

Impression: Acute marked sprain injury of AC ligaments and coracoclavicular ligaments of AC joint and distal clavicle, associated with one bone’s width of superior elevation of distal clavicle with respect to Acromion. Lack of adjacent bone marrow edema of soft tissue edema suggesting that chronic residual of posterior glenoid rim and/or posterior glenoid labrum may represent old rather than acute injury


Panel Qualified Medical Examination by Dr. M., MD at Orthopaedic Medical Group, Inc.

Neck pain, occasional bilateral shoulder pain and low back pain. While in college, sustained a right 4th metacarpal fracture and a contusion to the right thumb in 1999 which was treated and he appeared to recover well with immobilization. During summer of 2000, while exercising, sustained a stress fracture to right 5th metatarsal which required an intramedullary screw fixation. Operative procedure was performed on or about 08/14/2000 to that area. Sustained eversion and plantar flexion injury to right ankle on 12/13/2001, which had abnormal MRI scans on 04/22/2003 and 08/31/2003. On 09/29/2009, the patient was noted to have moderate effusion within left shoulder with small Hill-Sachs Lesion and some bone fragments within joint with a detachment of labrum. The problem was thought to be reverse bone and soft tissue Bankart lesion with SLAP lesion and fraying of the labrum. On 11/04/2010, roentgenogram of cervical spine disclosed disc space maintained and was thought to be normal with slight loss of normal lordosis.

Currently predominant complaint of some pain in low back, occasional pain in right hip and groin. Some occasional pain in shoulders with overhead use of arms. Intermittent slight-to-moderate pain in the low back present with repetitive bending, stooping, twisting or heavy lifting History of hypertension. He is on no regular medications. Does not smoke or consume alcohol. Normal neurological examination of the upper and lower extremities

Dr. M., MD reviewed records are as follows:

09/28/09 – Dr. B., M.D. – Diagnoses of healing, right 4th metacarpal fracture, right thumb contusion. At this point, no protection is needed.

04/08/10 – Dr. B., M.D. – Evaluation of hamstring strain, left leg. Ice and rehabilitation recommended.

Dr. opined that patient appears by his current subjective complaints and objective findings to reach a permanent and stable level with regard to spinal complaints specifically neck and back, which are only bodily parts that conceivably could have been related to some employment. The patient really never has a specific injury to neck or back while being employed.

The patient would be most appropriately classified as 0% WPI with respect to cervical and lumbar spine. This has been defined as no significant clinical findings, no muscular guarding, no documentable neurologic impairment, no significant loss of motion segment integrity, or other indications of impairment related to the injury or illness; no fractures.

Apportionment is a moot point because the patient does not have any permanent partial disability. Regarding future medical treatment, Dr. opined that there is no reason for ongoing care with regard to neck and back unless patient’s symptom complex changes in future. Only if he develops intractable radiculopathy and/or neurological problem, would he require MRI scans or sophisticated testing. At this point, over-the-counter analgesics or nonsteroidal anti-inflammatories and independent exercise should be sufficient.

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