Five Buzzwords to Look for When Determining Causal Relation in Workers Comp Claims

An MRI report is a useful tool used to determine if an injury is work related or caused by a different (pre-existing) condition. Remember, always use an IME or a Physician Peer Review to officially make this determination!

Injuries are always very similar in nature. Even when dealing with different people with different personalities, the objective medical evidence will come down to either being occupational in nature, or more related to someone’s ongoing degenerative conditions. Below we list some buzzwords to look for and what they can mean to the causal relation of an injury.

1. Complex tear

If a worker sustains a specific injury, due to an isolated incident, there is a good chance that any preliminary treatment will be related to the incident. But after a period of time, if the person is not getting any better, the doctor will send the worker for an MRI. This MRI will take a peek inside the joint to rule out if there is any internal derangement or not. Within the MRI report, if a tear is reported, that will not necessarily mean that the tear is directly related. In fact, unless this worker has had a prior MRI test, how does the employer determine or know what injury this person may have had in this joint before this incident occurred?

If the report lists a complex tear, this typically will relate to a tear of sorts, with some other medical issues going on in and around that area. Complex tears are usually several small tears within the area, sometimes without one specific massive large tear that can be pointed to as the pain generator. Complex tears can result over time, with several mini-traumas that cause the shoulder or knee joint to sustain numerous small injuries, usually not disabling in nature. Look for a larger tear within that area that can be related to support the ongoing disability. If the worker had a specific lifting incident, with complaints of a “popping” or “tearing” nature, this can indicate the causal relation showing that the incident worsened the person’s pre-existing condition of the several small tears by making one of those tears pathologically worse, resulting in the injury and increased pain complaints. Basically, if the word “complex” is in the MRI report, take a step back and look at the injury details, and see if it correlates.

2. Fraying

This also will be related to a tendon. Fraying can mean that the tendon is actually fraying apart. This usually indicates years of small injuries, enough to make the tendon literally fray apart. Think of the tendon as a rope, an older rope that has been through a lot of abuse will start to unwind itself, and begin to fray apart, weakening the overall strength of the rope. The same can apply to a shoulder or knee tendon. Years of abuse have caused the tendon to break apart, and weaken over time. If the worker had a specific incident of lifting and was sent for an MRI and the results indicate fraying, it does not mean that it is all necessarily related to work. However, if the worker complains of shoulder pain over a long span of time, fraying could be related to work exposure, depending on what job duties the worker does day in and day out. The physician will have to solve this mystery, so it will be important to look at the job duties this worker does, along with any other internal derangement that they have within that joint. Bone spurs or other general arthritic conditions can also result in fraying of the tendons, so be sure to do a thorough investigation so you can make the proper determination on the claim.

3. Acute

If the doctor uses the word “acute” in the medical reports when referring to specific damage within an MRI report, this could doom any effort to deem the claim unrelated to a specific work incident. Especially true if the worker had a legit specific trauma, acute damage can instantly correlate the internal derangement to the work exposure. Using a rope as an example again, if the rope looks good and is not fraying, but it has a gouge in it, without evidence of fraying or weakening, that is fairly concrete damage. These tears have clean edges, are easily spotted on the MRI films, and are typically the pain generator. Acute tears will arise out of twisting or lifting injuries, where the tendons are strained under the pressure of doing whatever activity the worker was doing at the time. If the doctor labeled a tear as acute, more often than not it will be related to a specific incident, and if the worker had this incident, this will likely be a compensable claim.

4. Multilevel degenerative disc disease

Moving to the spine, if an MRI shows multilevel degenerative disc disease, it is probably unrelated to work exposure. This condition is a condition of the body, typically unrelated to any specific work injury. Possibly if a worker claims that years of doing a heavy-duty job have led to “aggravation and acceleration of worsening of the spine” this could be potentially work related, but the doctor has to separate why that is, and how specifically the job duties tie in to it. Plaintiff counsel will always try to make this assumption, with long-term employees trying to make a case to say that the work exposure has rendered them disabled with a diagnosis of this degenerative disc disease. It can and has become compensable before, but the attorney has the work cut out for them. All of the chips have to line up perfectly, because most adjusters I know will be quick to issue a denial on a case with this diagnosis. Remember the burden of proof lies within the claimant.

5. Spondylolysis and spondylolisthesis

These two words are hard enough to say aloud and even harder to link to work exposure. These two conditions summarize a shifting of the vertebrae in the spine, which lead to more pressure placed on the discs, thus weakening them and making the discs more susceptible to injury, or worse, herniation. Similar to degenerative disc disease, Spondylolysis and spondylolisthesis are the cause of the actual diagnosis of the disc disease. Plaintiff counsel again will try to say that years of work exposure worsened this arthritic condition and accelerated it to the point of injury, but it is a stretch. I do not know of any work positions that specifically cause these conditions, but the presence of these conditions can lead to lumbar strains, due to the overall weakening of the spine. These claims start out as a lumbar strain, which will not resolve. After an MRI has confirmed these conditions, it is then that the adjuster will set the IME, to show that any ongoing pain is related to this arthritis, and not due to any minor lumbar strain. It does not mean that these words justify denying claims at will, but chances are that any treatment rendered directly to these conditions will not be accepted under comp, generally. It is possible though, so approach the physician to opine what is exactly related to a work incident, and what is due to ongoing degenerative condition advancement.

Summary

No matter what the MRI report will say, make sure to enlist a physician to help determine what is work related, and what is due to any arthritic condition. The key note here is no matter what the diagnosis, it does not mean you are out of the woods. Certain buzzwords can strengthen the defense, but all of the pieces of the puzzle are needed, including job descriptions and duties, duration of the employment, prior MRI reports, and medical records if any, and anything else the doctor will need to make the proper decision on compensability. The more information given to the doctor, the better decision the physician can make in regards to the causal relation of the injury.

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: [email protected].

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