An IW who has sustained a compensable injury is not limited to compensation of merely the compensable injury itself if the injury, or any proper or necessary treatment of the injury, causes other injuries in addition to the original compensable injury. Western Cas. & Surety Co. v. Gonzales, 518 S.W.2d 524 (Tex. 1975); Maryland Casualty Co. v. Sosa, 425 S.W.2d 871 (Tex. Civ. App.-San Antonio 1968, writ ref'd n.r.e. per curiam, 432 S.W.2d 515 (Tex. 1968)). The question to be resolved in an extent of injury issue is whether the claimed condition is causally related to or is a part of the compensable injury. APD 971725. Where the matter of causation of the claimed injury is beyond common knowledge or experience, expert evidence to a reasonable degree of medical probability is required. Houston General Insurance Company v. Pegues, 514 S.W.2d 492 (Tex. Civ. App.-Texarkana 1974, writ ref'd n.r.e.). The IW bears the burden to prove the extent of his or her compensable injury. APD 001602. Extent of injury is a question of fact for the HO to resolve. APD 960407; APD 050031-s.
Caused By Medical Care For The Compensable Injury.
Medical care causing further injury must be instituted to cure or relieve the IW from the effects of his or her injury. Hartford Accident & Indemnity Co. v. Thurmond, 527 S.W.2d 180 (Tex.Civ.App.-Corpus Christi 1975, writ ref'd n.r.e.).
Medical Care Caused Injury.
The IW was injured while picking up the tongue of a cement mixer. His neurosurgeon believed the IW ruptured a disc in his cervical spine and ordered a myelogram to determine the specific level. During the myelogram the IW felt three electrical sensations in his lower back and down both legs and immediately after experienced pain in his lower back. It was undisputed that the myelogram was required to treat the IW's compensable injury. The court held that although a myelogram is a complex medical procedure, a jury could infer a causal connection between the injection of the myelogram needle into the IW's spine and the immediate onset of back pain and numbness. Texas Employers Indemnity Company v. Etie, 754 S.W.2d 806 (Tex. App.-Houston [1st Dist.] 1988, no writ).
The IW sustained a compensable injury on April 18, 2001, to the cervical area and underwent cervical spinal surgery on August 7, 2002. On August 8, 2002, the IW began to have trouble communicating and weakness on the left side. It was determined that the claimant suffered from strokes. There was expert medical evidence in the record that the cervical surgery contributed to the strokes suffered by the IW shortly after the surgery. The AP affirmed the HO's determination that the IW's compensable injury extended to and includes strokes suffered after August 7, 2002. APD 032594.
The IW sustained a compensable injury on November 7, 2000. The IW received a pain block to treat her compensable injury of reflex sympathetic dystrophy. The IW contended that this medical treatment resulted in an extent of injury to her lumbar spine. The AP affirmed the HO's determination that the IW's compensable injury included injury to the low back. APD 012215.
Medical Care Did Not Cause Injury.
The IW sustained a compensable injury to her back. She underwent various diagnostic tests in the treatment of her compensable injury including a myelogram, and a lumbar and abdominal CT scan. Following her diagnostic testing the IW went back to the hospital the following day with headaches and nausea. While at the hospital she had a seizure. There was conflicting medical evidence as to the cause of the IW's seizure disorder. The HO determined that the IW's seizure disorder did not arise from treatment for the compensable injury and the AP affirmed. The issue was a question of fact for the HO to resolve and the HO's determination was supported by sufficient evidence. APD 971288.
Naturally Resulting From The Compensable Injury.
Injury is defined as damage or harm to the physical structure of the body and a disease or infection naturally resulting from the damage or harm. Section 401.011(26).
The Amarillo Court of Civil Appeals in the case of Maryland Casualty Co. v. Rogers, 86 S.W.2d 867 (Tex. Civ. App.-Amarillo 1935, writ ref'd), citing Travelers' Ins. Co. v. Smith (Tex.Civ.App.) 266 S.W. 574 (Tex. Civ. App.-Beaumont 1924, no writ), stated: "By the word `naturally', as used in the statute, it is not meant that the disease which is shown to have attacked the victim of the accident is such disease as usually and ordinarily follows the accident; but it is only meant that the injury or damage caused by the accident is shown to be such that it is natural for the disease to follow therefrom, considering the human anatomy and the structural portions of the body in their relations to each other." Id. at 871. However, the fact that an injury may affect a person's resistance will not mean that a subsequent injury outside the work place is compensable, where the subsequent disease or infection is not one which flowed naturally from the compensable injury. Texas Emp. Ins. Ass'n v. Burnett, 105 S.W.2d 200 (Tex. 1937); Traders & Gen. Ins. Co. v. Keahey, 119 S.W.2d 618 (Tex. Civ. App.-Amarillo 1938 writ dism'd).
Injury Naturally Resulted from The Compensable Injury.
The IW suffered compensable injuries to his left foot and right elbow. There was medical evidence that the IW subsequently suffered from neurosis. There was medical evidence that the IW's neurosis naturally flowed from his compensable injuries. The scope of an injury can encompass ancillary conditions which are connected to the injury. Hood v. Texas Indemnity Ins. Co., 209 S.W.2d 345 (Tex. 1948).
The IW sustained a compensable left ankle abrasion injury when she was struck by a pallet on a forklift. She later developed an infection (Pseudomonas Aeruginosa). The IW testified that she experienced pain, abrasions, and broken skin but no bleeding. There was no dispute that the site of the abrasion was where the infection occurred. There was expert medical evidence to support the hearing officer's determination that the infection naturally resulted from the compensable abrasion injury. The AP affirmed the hearing officer's determination that the IW sustained a compensable left ankle injury with resulting infection. APD 001287.
The IW sustained a compensable puncture wound to his right thumb in July 1998. The wound subsequently became infected, requiring three exploratory operations. Upon successful treatment of the infection, the IW continued to experience pain in his thumb, palm, and shoulder. Based upon the results of a bone scan indicating the presence of localized reflex sympathetic dystrophy (RSD) in the thumb, an aggressive RSD treatment program was recommended. The medical records reflect that the IW was examined by five doctors. Each of these doctors diagnosed RSD secondary to the thumb wound and resulting infection. The HO determined that the IW's compensable injury extended to include RSD and the AP affirmed. APD 010327.
Expert medical evidence.
Proof of causation must be established to a reasonable medical probability by expert evidence where the subject is so complex that a fact finder lacks the ability from common knowledge to find a causal connection. APD 022301, decided October 23, 2002. See also Guevara v. Ferrer, 247 S.W.3d 662 (Tex. 2007). To be probative, expert testimony must be based on reasonable medical probability. City of Laredo v. Garza, 293 S.W.3d 625 (Tex. App.-San Antonio 2009, no pet.) citing Insurance Company of North America v. Meyers, 411 S.W.2d 710, 713 (Tex. 1966). The mere recitation of the claimed conditions in the medical records without attendant explanation how those conditions may be related to the compensable injury does not establish those conditions are related to the compensable injury within a reasonable degree of medical probability. APD 110054, decided March 21, 2011.
Insufficient expert medical evidence to establish causation.
The IW injured her right shoulder while lifting clothing from a pallet and hanging them overhead. The IW alleged the compensable injury includes right shoulder impingement. An MRI performed included an impression of significant impingement. The AP noted the evidence reflects that no doctor diagnosed the IW with right shoulder impingement. The doctors only listed the MRI findings under tests performed. The AP further noted that there is no medical evidence explaining how a right shoulder impingement is related to the compensable injury. The AP reversed the HO’s determination that the compensable injury extended to right shoulder impingement because the finding in the MRI of impingement without attendant explanation how this condition may be related to the compensable injury does not establish the condition is related to the compensable injury within a reasonable degree of medical probability. APD 101323-s
The IW injured her lumbar spine when she slipped and fell at work. The HO determined that the compensable injury extends to an L4-5 disc protrusion with central stenosis, among other conditions. The AP found that although the designated doctor diagnosed the conditions at issue and then stated that the compensable injury should extend to those conditions, the AP noted that there was nothing in evidence that provides an explanation of how the mechanism of injury caused the L4-5 disc protrusion with central stenosis. APD 132953, see also APD 150750
The HO determined that the conditions at issue were compensable based on the DD’s opinion. The HO stated that the DD persuasively reasoned that the mechanism of injury was sufficient to cause the disputed conditions. The DD’s causation analysis stated that the IW indicated that an airplane chair closed on his arm and broke it. The DD went on to conclude that this mechanism of injury, along with the subsequent swelling and inflammation, was consistent with causing the disputed conditions. The AP noted that the DD’s opinion was based on an inaccurate understanding of the mechanism of injury, as neither the IW’s testimony nor the medical records showed that the chair closed on the IW’s arm and broke it. The AP reversed the HO’s extent determination as so against the great weight and preponderance of the evidence as to be clearly wrong and manifestly unjust, and it rendered a new decision that the compensable injury did not extend to the disputed conditions. APD 171082
The IW testified that he injured his back while attempting to straighten a part of the production line that was bent. The HO found that the compensable injury extends to stenosis at L4-S1, disc protrusion at L5-S1 on the left, facet hypertrophy at L4-5, and S1 radiculopathy based on a letter of causation from the treating doctor. However, the AP noted that the treating doctor did not identify the specific findings he is referencing nor did he refer to a diagnostic test which would identify the specific conditions. The AP reversed the HO’s determination that the compensable injury extends to the conditions in dispute. APD 132180
Sufficient expert medical evidence to establish causation.
The IW was injured when she fell and fractured her left ankle. The HO determined that the compensable injury did not include a stress fracture of the left second metatarsal, because the causation opinion in evidence failed to rule out other possible causes of the stress fracture. The AP noted that an analysis of other possible causes of an injury or illness is a factor to consider when determining causation, however, the Supreme Court in Crump did not hold that the only method to establish expert medical causation is by differential diagnosis. The AP reversed and remanded the HO’s determination because the HO misinterpreted and misapplied the law by requiring a differential diagnosis. APD 120311-s
The IW was injured when she stepped in a crack and rolled her right ankle. The HO determined that the compensable injury does not extend to plantar fasciitis and complex fasciitis, and complex regional pain syndrome/reflex sympathetic dystrophy (CRPS/RSD) of the right lower extremity. The HO found that the letter of causation in evidence from the treating doctor in regard to those conditions was conclusory because it merely recited the MRI findings, CRPS diagnosis, and a statement that they are related to the compensable injury. However, the AP noted that the causation letter additionally discussed the claimant’s mechanism of injury and how the torqueing forces caused the disputed conditions. The AP reversed the HO’s determination because the HO misread the causation letter and considered it as though there was no sufficient expert medical evidence regarding causation of the disputed conditions. The extent- of-injury issue was remanded for the HO to fully consider the causation letter and give it proper weight. APD 130723
The IW testified that he injured his back while moving boxes at work and contended that the compensable injury extends to a 4 mm broad-based disc bulge at L5-S1, lumbar radiculopathy at L5-S1, or Grade I spondylolisthesis (approx. 6-7 mm of anterior displacement of L5). The HO determined that the IW did not meet his burden of proof on the issue because the designated doctor, whose opinion the IW relied on, did not provide a causation analysis. However, the AP noted that the designated doctor stated in part that the 4 mm broad-based disc bulge and L5-S1 radiculopathy were caused by the injury, that the IW had Grade I spondylolisthesis on x-rays and stated the mechanism of lifting and twisting has resulted in the disc bulge and resulting spondylolisthesis, which in turn resulted in the nerve root injury. The AP reversed the HO’s extent-of-injury determination because the designated doctor did provide some analysis for his opinion that the conditions in dispute were part of the compensable injury. The HO misread the designated doctor’s causation opinion. The issue was remanded to the HO to consider the opinion. APD 142257
The IW injured her left knee and ankle when she tripped over the leg of a passenger as she was pulling a cart down the aisle of an airplane. The HO determined in part that the compensable injury extends to medial and lateral meniscus tears of the left knee, chondromalacia of the patellar femoral joint including femoral trochlea of the left knee, and Piriformis syndrome. However, in the Discussion portion of the decision, the HO noted that the IW’s physical therapist provided an explanation of how the Piriformis syndrome resulted from the compensable injury. The HO stated that the physical therapist’s opinion is not considered an expert medical opinion on causation because it is not from a physician. The HO went on to find sufficient causation evidence from the designated doctor to determine the compensability of the Piriformis syndrome. The AP affirmed the HO’s extent-of-injury determination, but explained that the HO erred in failing to consider the physical therapist’s opinion. Although a physical therapist is not listed under the definition of “doctor” in Section 401.011(17), medical evidence may be generated by a number of sources other than by individuals who are defined as “doctors” in Section 401.011(17). That medical evidence may be in the form of a physical therapist’s reports and notes, and by any number of other health care providers. APD 150372
Expert medical evidence is not required.
Conditions that are within the common knowledge and experience of the fact finder do not require expert medical evidence to establish causation.
The Appeals Panel has long held expert medical evidence is not required for strains. See APD 120383, decided April 20, 2012, where the Appeals Panel rejected the contention that a cervical strain requires expert medical evidence, and APD 992946, decided February 14, 2000, where the Appeals Panel declined to hold expert medical evidence was required to prove a shoulder strain, and APD 952129, decided January 31, 1996, where the Appeals Panel declined to hold expert medical evidence was required to prove a back strain.
The IW testified he was injured when he fell from a ladder while painting. The HO determined in part that the compensable injury extends to a left knee injury in the form of a sprain, but does not extend to Grade II cervical sprain/strain at C3-4 and Grade II lumbar sprain/strain at L2-3, L3-4, and L4-5. The HO stated in the Discussion section of the decision that the disputed conditions appear to be called sprains/strains, but include a Grade II degree of those sprains/strains and are further classified as being tied to various disc levels as would be disc pathology in the nature of a herniation or protrusion. The HO further stated that the disputed conditions would go beyond the accepted condition of sprains of the cervical and lumbar spine and would require expert testimony in order to determine the nature of the injury as described in the disputed issue. The AP disagreed that the disputed conditions go beyond the cervical sprain/strain and lumbar sprain/strain accepted by the carrier, especially in light of the fact that medical records in evidence use the same diagnosis codes interchangeably for cervical and lumbar sprain/strain and Grade II cervical and lumbar sprain/strain. The HO’s extent-of-injury determination was reversed and rendered in favor of the IW. APD 130808
The IW was injured when she stepped on an air conditioning vent in the floor that gave way. The HO determined in part that the compensable injury does not extend to a herniation at L4-5 with nerve root irritation [sciatica], sprained talofibular ligament, and fibromyalgia. The HO stated in part that the sprained talofibular ligament was beyond common knowledge and that an expert medical opinion was required for a specific ligament despite the accepted ankle sprain/strain. The AP noted that since the alleged extent-of-injury condition to the left ankle at issue is specific to a particular ligament, the condition should be diagnosed in the medical records. However, the AP further noted that it cannot agree that just because the alleged sprain/strain is to a particular ligament that it elevates the condition of a sprain/strain to a level that is so complex that a fact finder lacks the ability from common knowledge to find a causal connection. The issue of extent to the sprained talofibular ligament was remanded to the HO because a higher standard than is required under the law to establish causation was required. APD 141478
The IW sustained a compensable injury in the form of at least a right ankle sprain and a left shin contusion. The HO determined that the compensable injury does not extend to a thoracic sprain/strain, a lumbar sprain/strain, and a right knee sprain/strain. The HO noted that there is an attenuation factor in this case and specifically stated that as such, expert medical causation evidence was necessary to establish a causal link between the claimed conditions and the compensable injury. The AP disagreed that an attenuation factor in and of itself would mandate expert medical evidence of causation to establish compensability of a sprain/strain. The AP stated that a delay in the onset of symptoms was merely a factor for the HO to consider in determining whether the IW had sustained his burden of proving a causation connection between the disputed extent-of-injury conditions and the compensable injury. The HO’s determination was reversed and the issue of extent was remanded to the HO to consider the evidence and apply the proper evidentiary standard of causation. APD 141688
The IW was injured when she was assaulted by a patient which resulted in loss of consciousness when her head hit a metal seclusion door frame. The HO determined in part that the compensable injury extends to concussion and impaired concentration but does not extend to post-concussion syndrome, left posterior parietal hematoma/contusion, post-traumatic stress disorder, headaches, and depression. Regarding the condition of headaches, the AP noted that it was undisputed that the claimant’s head struck a metal door frame with such force that she lost consciousness and numerous records in evidence from two days after the date of injury onward diagnose the claimant with headaches. The AP stated that under the facts of this case and with the described mechanism of injury, we decline to hold that expert medical evidence was required to prove headaches. That portion of the HO’s extent determination that the compensable injury does not extend to headaches was reversed and rendered as being against the great weight and preponderance of the evidence as to be clearly wrong and manifestly unjust. APD 142523
The IW was injured while he was working as a prison guard and was assaulted by an inmate on the date of injury. The stipulated compensable injuries were a nasal contusion, lip laceration, and cervical strain. The HO determined in part that the compensable injury does not extend to the diagnoses of cervical disc bulges at C2-3, C3-4, C4-5, C5-6, and C6-7, disc protrusion/herniation at C5-6, nasal bone fracture, concussion, traumatic brain injury with post-concussion syndrome/seizure disorder—epilepsy. Regarding the nasal fracture, the AP noted that the IW was punched to the face several times by an offender and went to the hospital where he received stitches to his lower lip area. Additionally, the first x-rays were taken of the IW’s nasal bones, six days after the date of injury, and noted that the IW had a fracture of the tip of the nasal bones. The AP stated that under the facts of this case, with the described mechanism of injury, we decline to hold expert medical evidence was required to prove a nasal bone fracture. The HO’s determination that the compensable injury does not extend to a nasal bone fracture was reversed and rendered as being against the great weight and preponderance of the evidence as to be clearly wrong and manifestly unjust. APD 141556