Repetitive motion injuries result from the repeating tasks required by certain jobs. It is also referred to as RSI or Repetitive Strain Injuries or Repetitive Stress Injuries and involves the musculoskeletal and nervous systems. These injuries can result from a number of factors such as:

• awkward and sustained positions
• forceful exertions
• pressing against a hard surface (or mechanical compression)
• repetitive tasks
• vibrations

Non-specific arm pain and upper limb work-related disorders are also included where RSI’s are concerned. In many cases of this nature, it is apparent that psychosocial and physical stressors play a significant role in these types of injuries.

RSI Symptoms

Patients who have been diagnosed with RSI typically experience the following symptoms:

• lack of endurance and weakness
• pain experienced in the arm, back, hands, shoulders, and/or wrists
• pain that worsens with activity

When you contrast RSI injuries with CTS injuries, the symptoms of the latter tend to be both diffuse and non-anatomical in nature. It crosses the proper distribution of nerves and tendons as well as not being characteristic of specific discrete pathological conditions.

Ms. A and her bilateral CTS case

Ms. A is a candidate for bilateral CTS surgery due to injuries incurred from a bilateral injury to her upper extremities while performing her job. Her job required a great deal of repetitive arm and hand work as she cut and made fiber optics. Despite experiencing pain in her upper extremities, she continued to work until she was no longer able to. Her employer referred her to Dr. S who began treating her with physical therapy. When her conservative care and PT didn’t relieve her pain, she was referred to Dr. B.

Dr. S splinted her arms and put her on “light duty” status. Unfortunately, there was no light duty work for her on the job and she could no longer perform regular work, so she was sent home and remains on full disability (temporary total disability) to this day.  Dr. S ordered an MRI for Ms. A and it revealed that she had lateral epicondylitis partial thickness tearing in the proximal common extensor tendon. The proposed treatment is an initial surgery on Ms. A’s right elbow. Once the right elbow heals, she will have surgery on her left elbow.

Ms. A is now considering whether or not to settle.   On one hand, there is a high degree of  uncertainty with regard to the nature, extent and future cost of future medical care.   Often settlement values are higher when the insurance company is facing open ended medical costs.  On the other hand, if my client settles and her future medical needs involve multiple surgeries and physical therapies, even a settlement of $100,000 or more will not adequately compensate her.  This dilemma of whether and when to settle is one of the more difficult decisions for a significantly injured workers' compensation claimant.

"Mr. L," a private investigator, received significant injuries when he was working a case in bad weather. He was involved in a serious automobile accident when he lost control of his vehicle and crashed into a large pine tree. His airbags deployed and his vehicle was damaged on both sides. As a result, he incurred injuries to his cervical spine, chest, left arm, right elbow, and right shoulder.

He would be treated for his injuries in the local ER and then released into the care of two doctors (Doctors M and N) where he would receive necessary follow-up care. The condition of his cervical spine could not be treated by Doctors M and N, so he was referred to Dr. S for specialized care and further testing. Dr. S performed a CT scan and an EMG. During this time, Mr. L continued to work his PI job when he was confronted by a police officer, arrested, and then handcuffed in the process.

As the arresting officer handcuffed him, he forced the man’s neck and shoulder into a position which resulted in further injury to Mr. L, therefore creating further problems for him! At this time, Mr. L went into the care and treatment of Dr. P, an orthopedist. Dr. P immediately discovered the injuries that Mr. L received during the arrest and diagnosed them as “a right C 6-7 radiculopathy; herniated disc and stenosis at C5-6; as well as a partial rotator cuff tear of the right shoulder.”

In September of 2005, he was referred to a surgeon who would perform “anterior cervical discectomy and fusion with plating.”  The surgeon also placed him on what is called a “no work” status. In other words, he was forbidden from working since he was always in pain and movements that were typically performed on the job could no longer be made. He began receiving regular TTD payments of $394.52. Additionally, he was treated with a bone stimulator to assist with the fusion part of his treatment.

In addition to the bone stimulator, Mr. L was also being treated by having to wear a hard neck brace for the ensuing several months. Additionally, he was prescribed numerous medications including Celebrex, Reglan, and Ultracet because of his intense pain and his limited ROM or Range of Motion. To this day, Mr. L continues to live with neck pain and according to Dr. D, the extent of the damage to the man’s cervical spine is now a source for the chronic pain he has been diagnosed with.

Mr. L continued living in pain and a restricted ROM because of the torn rotator cuff in his right shoulder. He continues to be under the care of Doctors A and P. At that time, arthroscopic surgery was performed on the injured shoulder which didn’t relieve his pain or his symptoms. Despite the fact that Mr. L attempted to go back to work as a PI, it was immediately apparent that the injuries to his right arm and shoulder would cause significant pain so he could not properly perform his job any longer.

At this time, Dr. P also performed another surgical procedure wherein Mr. L was anesthetized and the doctor tried to manipulate his shoulder in order to relieve his pain. To this date, he still encounters pain and discomfort when driving. Everything to this point had failed to ease Mr. L’s symptoms despite his continued medication and therapy. He was then referred (again) to Dr. A for a consult and then a decided-upon treatment. At that point in time, a post-surgical MRI revealed the full extent of Mr. L’s injuries.

Dr. A performed three different procedures including surgery to repair his torn rotator cuff. After this time, Mr. L went to Dr. M for an IME (independent medical examination) where several things were documented such as:

• constantly aching shoulder
• pain encountered with movement overhead
• rotator cuff issues

Mr. L continues to need medication and ongoing pain management. Neither post-surgery medications nor therapies have helped Mr. L live without pain or limited ROM. He is restricted with the amount of hours that he can perform functions including:

• standing
• walking
• sitting
• reaching overhead
• lifting
• pushing
• pulling

He can occasionally bend, crouch, kneel, or stoop; drive no more than 30 minutes at one time; and cannot operate dangerous machinery because of his pain medications.

Since his last surgery, Mr. L's medical condition has not changed very much and after reading through the medical records I discussed with Mr. L the advisability of settlement.   Mr. L had indicated to me that while he would not be resuming his career as a private investigator, he was exploring other avenues to earn money.  Because he had been a private investigator, he readily understood that the insurance company would likely put  him under surveillance and that if he was seen engaging in any significant activity, the insurer would move to cut off his benefits.  We decided that this was a good time to settle and after several weeks of negotiation the insurance company agree to pay well over six figures.

According to government statistics,  nearly 20% of all the work-related injuries involve back injuries and back pain, especially lower the back area.   The cost of these work injuries continues to soar – currently estimates put the cost of treatment and lost productivity at nearly $20 billion annually.   Not surprisingly many of the cases I see involve some form of back injury – ranging from cervical (neck) damage to lumbar and thoracic (mid to lower back) injuries.   In my experience, quick diagnosis and treatment can greatly improve the chances of a more complete recovery.

General causes of back injuries

Back injuries can result from numerous causes including:

• Heavy lifting
• Remaining in the same position for too long and too often
• Repetitious activities and movements
• Stressful lifestyles

Back braces and modified lifting techniques can help but not prevent back injuries.

The back injury case of Mr. S

Mr. S worked for a company that owned several large trucks.   The company was selling several of its trucks and Mr. S's supervisor directed him to show the truck to a potential customer. Mr. S was attempting to push open the hood of the truck when the hood (weighing 300 lbs.) detached and fell on him, pinning him to the floor.  Mr. S  began experiencing pain in his lower back as well as radiating pain in his leg.

This accident was witnessed by both the potential truck buyer and Mr. S’s supervisor, who instructed Mr. S to go to one of the posted panel doctors.   Upon arriving at the doctor’s office, Mr. S noted that the line of patients was out the door and since he did not want to sit around and wait, he decided to return to work and took pain medication before returning to the job. Mr. S continued working for the next 4 months, relying on over the counter pain pills to reduce his pain.  At no point did he ever actually meet with a doctor.

Around 4 months later, Mr. S again injured his back while working on a truck.  This time, he felt a definite "pop" and his legs went numb.  The supervisor again sent Mr. S to a  posted panel doctor who took Mr. S off work and began conservative treatment (prescription pain pills and physical therapy)  When Ms. S was unable to perform the exercises during physical therapy, the panel doctor ordered an MRI.  The MRI revealed several bulging discs as well as 2 herniations with impingement on the spinal cord.

The panel doctor then referred Mr. S to an orthopedist for surgery.   Mr. S was not impressed with the surgeon and he emailed me with his story to ask if he had any options.   I suggested to him that if I was dealing with the same injury I would want to be evaluated by a specific neurosurgeon, and I also explained what Mr. S could expect in terms of rehab and case settlement.  At that point, Mr. S retained me to serve as his lawyer.

Once I was retained I contacted the insurance adjuster and suggested that we agree that Mr. S should be seen by a neurosurgeon who I know to be very capable.  The adjuster agreed (to my surprise) and my client underwent a multi-level fusion, which my client underwent.

There was one other interesting twist to this case – at the time my client was seen by the original panel doctor for the second time, the adjuster assigned a nurse case manager to assist with my client's care.  For those of you who are not familiar with the role of the nurse case manager, she is a nurse who works on behalf of the insurance company to facilitate care.  Sometimes, nurse case managers can be helpful in cutting through red tape – such as getting diagnostic reports like MRI films to a doctor. In other instances, the nurse case manager can interfere with treatment by advocating on behalf of the insurance company – for example I have seen cases where a nurse case manager attempted to influence a treating doctor to return a claimant to work too early.

Years ago, the insurance company had a right to assign a nurse case manager.  Under current law that right exists only in catastrophic cases.  Otherwise the claimant (usually through counsel) can terminate the involvement of the nurse case manager.

In this case, we had to do just that.  The nurse case manager was attending my client's medical exams and she was pressuring the surgeon to speed up the rehabilitation process.  I felt that her motivation and value were in question and I advised the adjuster that we no longer needed her services.

Severe ankle and foot injury Workers’ Compensation case

This case involved an ankle injury incurred by woman (Mrs. K) who worked in a warehouse environment.   While moving a bulky 250-pound steel panel, Mrs. K and her co-workers paused to rest after moving the steel panel only about 10 feet.   The panel became extremely unsteady and fell on her Mrs. K's foot, snapping and breaking the ankle and foot.   Mrs. K was immediately rushed to her local hospital’s ER where she would undergo surgery to stabilize and immobilize the fracture.

After her surgery, Mrs. K was referred to a physician from the posted panel of physicians who saw her 3 days after her surgery.  Despite the severity of her fracture, the panel physician did not take X-rays to evaluate the union of the bones, nor did he conduct any nerve function tests to evaluate any possible loss of function.  Instead he left the cast on and prescribed pain medications.

After just over a week living in intense pain, Mrs. K.  found me through my web site and retained me to represent her.  After reviewing the medical record, it was obvious to me that Mrs. K needed additional surgery and she needed a surgical consult quickly.  I contacted the insurance adjuster and persuaded the adjuster to refer my client to a foot and ankle specialist.   The foot and ankle specialist diagnosed the foot fracture as a "displaced" fracture, meaning that another surgery was needed and that plates and screws would have to be used to stabilize the foot.  This, of course, means that a third surgery likely would be necessary to fully or partially remove this hardware.

Because of the delay in getting Mrs.  K to the appropriate physician, she suffered complications – ecchymosis (skin discoloration) up the leg to her knee and neuropraxia (loss of nerve function) throughout her foot.    In my opinion, these complications would not have occurred, or would have been less severe had the 2nd surgery been performed earlier than it was.

Mrs. K is still recovering from surgery.   Her job had required her to stand, squat, lift and stand, and she cannot perform the duties of her past job.  Rehabilitation is proceeding slowly and I estimate that she will be out of work for at least 6 to 8 months.

Mrs. K has not yet had her second surgery and it is not clear to me how invasive that second surgery will be.   I expect that we will make a settlement demand either before or after the second surgery.

In my view, this is a case in which the insurance company's delay and their reluctance to get Mrs. K to the right doctor quickly on what was clearly a surgical case will dramatically increase the settlement value of this case.  More importantly, I am of the opinion that my client's health was compromised by the insurer's delay, not to mention the unnecessary suffering she experienced.   I further suspect that had she waited 3 or 4 weeks before hiring me, a second surgery would not have been scheduled as the initial panel doctor seemed oblivious to the severity of this injury.

This case illustrates the importance of recognizing that medical treatment under workers' compensation can be substandard and inadequate.  The panel doctor's motivation and loyalty was not to his patient, but to the insurance company.  Ironically, the panel doctor's failure to act will end up costing the insurance company more money.

Cervical injuries made worse by returning to the job

Mrs. B is a 20-year employee of a medical practice.  As the office manager, she was involved in all facets of managing the practice, including patient care, insurance submission, and handling other patient paperwork.   Mrs. B is also a licensed practical nurse and she also served as a nurse, frequently making rounds with doctors at the hospital during her work shift. Mrs. B was injured when she felt a "pop" in her neck while assisting two co-workers move office furniture and other office equipment.

After moving the furniture and equipment, Mrs. B started to experience severe pain in the arms and neck.   Additionally, she noticed that she had numbness and pain in her right leg. Despite her pain and numbness, Mrs. B. returned to work the next day and continued working for 9 full months until the pain and discomfort became so intense at she could not function.   Finally, Mrs. B returned to the panel physician who took her out of work and prescribed pain pills and physical therapy.

Perhaps because Mrs. B has a medical background, she sensed that the care she was receiving under workers' compensation was not sufficient, so she decided to seek counsel, even though she was receiving her weekly income benefits of $500 per week and the employer/insurer was not denying her claim.

When I got involved in this case, I recognized that Mrs. B's injury was most likely a surgical problem.   After reviewing literally thousands of pages of medical records, I have a fairly good sense of which doctors I like my clients to see for various medical problems and I wanted Mrs. B to see a particular surgeon.   The insurance adjuster would not agree to my preferred doctor so I directed my client to return to her panel physician and request a referral to this particular doctor, which he agreed to do.   Under Georgia law, this referral from an authorized treating physician to another physician must be honored by the insurance carrier and the adjuster reluctantly agreed to authorize my preferred surgeon.  In my view, all parties – my client and the insurance company will benefit from this surgical referral as my preferred surgeon is one of the best specialists in the state for neck surgery.

Mrs. B underwent a multi-level cervical fusion and followup rehabilitation.   Mrs. B had expressed a desire to return to her job but, as I expected, the insurance carrier demanded a resignation as part of any settlement.  Mrs. B recognized that she would not be able to return to her past work and she authorized me to enter in to settlement negotiations.  Our final settlement consisted of cash and 24 months of "open medical" care with the surgeon

Outstanding medical bills and your credit

One of the most common sources of damage to a person’s credit is outstanding (unpaid) medical bills.  If you are injured on the job, your medical bills should be covered by your employer's workers comp insurance company.  Not surprisingly workers' compensation insurers can be slow in paying medical bills and your credit may be the casualty in such a situation.   I have been retained by several clients to handle this issue because of the frustration and anger they feel when bill collectors start calling about medical debt that should have been paid weeks or months earlier by the insurance company.

Group Health vs. Workers' Compensation: a Recipe for Confusion

Under Georgia workers' compensation law, bills relating to your treatment from authorized treating physicians must be paid timely.  The law also provides that workers' compensation insurance is "primary" – meaning that group health does not come into play when there is valid workers' comp coverage.  Sometimes injured workers submit bills to a group insurance company because a supervisor instructs them to do so or because they do not realize that workers' compensation is the primary insurance source.

If the group health carrier identifies your claim as a workers' comp. claim, it will deny coverage.  If the physician's office has coded the claim incorrectly it may send your account to a collection agency.   You may be caught in the middle trying to explain to a disinterested bill collector that your bill is covered by insurance, or you may find that the "authorized" treating doctor will refuse to treat you because of "unpaid" bills.

Recently, I represented an injured worker who found himself facing both collection and a refusal by his doctor to treat because of the outstanding balance.   When we settled this case, I insisted that a provision for future medical care must be included in the settlement.  Our settlement provided for:

• monetary compensation for my client in the amount of “X” dollars
• a confirmation that the health carrier has paid for all the current bills and will pay for any future bills from Dr. "W"
• Dr. "W" must confirm with the group carrier that he does not need any further reimbursement until further services are rendered
• medical payments and TTD continue being paid to my client pending approval of the settlement by the State Board

Please feel free to call me at 770-351-0801 if you are getting the run-around with regard to your medical bills or medical treatment.

The case of "Mr. F," a long-term employee with multiple injuries

“Mr. F” has been employed by his company for 26 years as a machine operator and is required to maintain, repair, and run the machinery he is responsible for. He also operates a forklift in order to stock supplies. As a result of his job responsibilities, Mr. F sustained significant cervical and lumbar spine injuries as well as significant knee damage. His medical records indicate that he has continued to encounter pain and problems in these physical areas.

Mr. F’s treating physician (Dr. V) firmly believes that knee surgery is inevitable and that cervical and lumbar spine pain will be ongoing. To date, Dr. V continues to provide Mr. F with treatment in the hopes of relieving his pain. Due to the fact that the TTD has been reduced, Dr. V placed the man on “no-work” status so he did not lose the original amount of compensation for being unable to work due to his injuries. PPD ratings were also assessed which will be due and payable in the future.

Given the nature of Mr. F’s injuries and the residual problems which resulted from performing his job and will continue for years into the future, it is evident that his employer and insurer are responsible for compensating the man. As a result from the aforementioned circumstances, we have demanded a settlement in the amount of “X” and are awaiting a favorable settlement of our client’s case.

An overview of DeQuervain’s Syndrome and Lateral CTS

DeQuervain Syndrome is also nicknamed Mother’s Wrist or Washerwoman’s Sprain. In more medical, technical terms it is known as de Quervain's tenosynovitis, de Quervain's stenosing tenosynovitis, or Radial styloid tenosynovitis. DeQuervain’s syndrome is an inflammation (or tendinosis) that occurs in the sheath or the tunnel which surround the two tendons which are responsible for the thumb’s movement.

Carpal Tunnel Syndrome or CTS is also referred to as median neuropathy at the wrist and is a condition that results from a compressing or pinching of median nerve in the wrist area. It typically leads to extreme pain, muscle weakness, and numbness of the hand. Night symptoms and waking up off and on are characteristics of CTS as well. The definitive or standard treatment of the condition is a surgical procedure known as carpal tunnel release.

It should be noted that although this surgical procedure effectively relieves the symptoms of CTS, established nerve dysfunction in the form of atrophy, constant or “static” numbness, and weakness are all permanent. Ironically, most CTS cases do not have a specific cause, and some individuals are predisposed at developing the condition based on genetics.

Workers’ Compensation case involving repetitive motion injury: The case of “Ms. C”

Our client, Ms. C, was diagnosed with bilateral CTS as a result of her repetitious work in cake decorating. According to Dr. D, she was diagnosed with “bilateral DeQuervains tenosynovitis and ulnar nerve injury.” As a result of Ms. C’s injuries, she underwent surgeries on both wrists. About 6 weeks later, she went through surgical procedures on the left wrist – carpal tunnel and DeQuervains release surgery.

Ms. C continues living in pain today, even after the different surgeries were performed. Pain is prevalent especially in the hand, at the incision, and in the wrist area. She is currently undergoing physical therapy and has limited range of movement (ROM) as well as the pain mentioned in the above areas. It is evident that she will continue to remain under medical care as well as receiving TTD for quite some time.

Given the residual problems that exist and her surgeries, the PPD (Permanent Partial Disability) rating of each wrist is 10%. Additionally, due to the repetitive nature of Ms. C’s work, it is very obvious that her capacity to perform her job has been severely limited and she will experience continued levels of pain. As a result of her case, we have demanded “X” amount in her Workers’ Compensation case and are awaiting settlement

What is Reflex Sympathetic Dystrophy?

CRPS or complex regional pain syndrome as it is technically known by is a progressively chronic disease that is characterized by changes, pain, and swelling of the skin. It is a disease which to date has no cure and has been divided into 2 categories (see below). Nerve lesions are often present after the injury has occurred.

CRPS Type I was originally called RSD or Reflex Sympathetic Dystrophy, and Type II was originally known as Causalgia. The key difference between the two types is that Type I does not typically result in nerve lesions whereas Type II displays significant nerve damage. Not only is there no cure for the disease, there is no apparent cause to this condition. Injury followed by surgery is typically a precipitating factor. However, there have been cases documented that show no injury actually occurred to cause CRPS or RSD.

Workers’ Compensation and RSD: The case of “Ms. F”

The case involving Ms. F, a Macy’s sales associate, is one in which she suffered an RSD injury as a result of a heavy sales sign falling from a display table and injuring her left ankle. Her pain was immediate and she was taken out of the store in a wheelchair. She was taken to the ER at a local area hospital where she was diagnosed with a contusion and laceration of the left ankle. Upon receiving her diagnosis, Ms. F was then taken to urgent care for further treatment. Unfortunately, her pain was not reduced.

Ms. F was then referred to an orthopedist (Dr. C) who treated her in conservative fashion. However, this did not diminish her pain levels either. Additionally, she was unable to walk. As a result of her inability to walk and her pain levels, Dr. C ordered an MRI which revealed the extent of the damage to her ankle. The metaphysic area of her distal femur had a small lesion apparent in the MRI. Dr. C determined that this was indicative of an RSD injury and he then referred Ms. F to Dr. L who performed NCS (Neurocardiogenic Syncope).

Dr. L determined that Ms. F has suffered a “2nd degree left peroneal motor nerve injury distal to the ankle.” In simple terms, my client had sustained permanent nerve damage due to the work injury. Her injury had already required extensive and costly treatment, and it would likely continue to do so.

To this date, she is under a new doctor’s care; Dr. L referred her to a RSD specialist. The client has been unable to work since the date of the incident, and it appears that she will be out of work indefinitely. Based on the above circumstances, our firm demanded “X” amount as a settlement for Ms. F’s case, and we successfully got our client the settlement she needed to cover the costs of ongoing medical care, lost income from not being able to work, rehabilitation costs, etc.

• if your employer does not provide a valid "posted panel" of physicians you may be able to seek care with any physician and your employer and its insurer must pay for this care
• you can switch between one posted panel physician to another without prior permission
• you can request  a change in authorized treating physician
• you can request a claimant's IME

The claimant's IME is a very interested feature of Georgia law.  First enacted in 1990, Section 34-9-201(e) provides that an injured worker can demand an independent medical exam with a physician of his choice, paid for by the workers' comp. insurance carrier.  In my practice I use this "claimant's IME" frequently to get a second opinion about questionable existing care or as evidence to support a request for permanent change in authorized treating physician.

Of course your right to a claimant's IME under Georgia law is not absolute – I recently wrote an article about this topic on one of my web sites.   Take a look if you are not happy with the quality of medical care you are receiving – and let me know what you think.