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Over the past year, we have been periodically publishing posts about strategies to improve decision making that are based on an article Jeffrey Brewer wrote on the topic.  Our prior posts addressed the first nine of the ten individual strategies Brewer outlined:

  1. Consciously raise the questions, “What do we know…?  How do we know…?  Why do we accept or believe…?  What is the evidence for…?” when studying or approaching a problem.
  2. Be clearly and explicitly aware of gaps in available information.  Recognize when a conclusion is reached or a decision is made in absence of complete information and be able to tolerate the ambiguity and uncertainty (which can be painful in the medico-legal-claims environment where the goal is total predictability).  Recognize when one is taking something on faith without having examined he “How do we know…? Why do we believe…?” questions.
  3. Discriminate between observation and inference, between established fact and subsequent conjecture.
  4. Recognize that words are symbols of ideas and not the ideas themselves.  Recognize the necessity of using only words of prior definition, rooted in shared experience, in forming a new definition and in avoiding being misled by technical jargon.
  5. Probe for assumptions (particularly the implicit, unarticulated assumptions) behind a line of reason.
  6. Draw inferences from data, observations, or other evidence and recognize when firm inferences cannot be drawn.
  7. Perform hypothetico-deductive reasoning, that is, given a particular situation, apply relevant knowledge of principles and constraints and visualize, in the abstract, the plausible outcomes that might result from various changes one can imagine being imposed on the system.
  8. Discriminate between inductive and deductive reasoning; that is, be aware when an argument is being made from the particular to the general or from the general to the particular.
  9. Test one’s own line of reasoning for internal consistency and thus develop intellectual self-reliance.

At long last, we have come to Brewer’s tenth and final step, where we put all the prior steps together:

  1. Developing self-consciousness concerning one’s own thinking and reasoning process.

Before we address the final step in detail, we must review why we are concerned with decision making in the first place.  The chief reason is that a plethora of scientific research tells us that detrimental cognitive biases and heuristics infect our decision making if we do not adopt a systematic approach to control and limit their effects.  Brewer’s strategies for improving our decision making offers just such a systematic and rational approach to limiting the effects of cognitive biases and heuristics. 

A short review of how cognitive biases and heuristics detrimentally effect decision making is also in order before we get to the final step.  One heuristic that often arises in the medico-legal context is the association of correlation with causation.  Thus, we frequently are faced with ALJs, circuit court judges, and juries who conflate correlation with causation and assign legal causation based on temporal proximity rather than actual causation.  Hence, in the worker’s compensation setting ALJs often conclude that employment activities caused or aggravated a low back problem simply because the worker experienced pain while working.  It is incumbent on us to understand this casual but unconscious heuristic so that we can introduce persuasive evidence to attack it and demonstrate that it is fallacious reasoning. 

One cognitive bias that often arises in the medico-legal context is the confirmation bias, which causes us to overweigh information consistent with our position (i.e. that the employee’s complaints are not related to the workplace accident) and to under weigh information that is inconsistent with our position (i.e. the employee’s complaints are related to the workplace accident).  Failing to have a strategy to reduce the effect of the confirmation bias will cause us to persistently and unconsciously overestimate the strength of our position.  This in turn is likely to persistently compromise our ability to settle claims and lead to bad results.  Of course the good news is that both sides are subject to the same cognitive biases and heuristics.  Thus, if we can limit their effects on our decision making, we will be at a comparative advantage. 

So now that we know why developing a consistent decision making strategy is important, let’s get back to Brewer’s final step:  to develop self-consciousness concerning one’s own thinking and reasoning process.  This step involves reflecting upon the decision making processes one is using, deliberately invoking those steps that are most appropriate to the given circumstances, and consciously transferring those reasoning methods from familiar to novel contexts.  In other words, the final step is to internalize the decision making process so that we automatically follow it in every case, new or old.

In essence, Brewer wants us to have a method for problem-solving that is second nature, which will ensure that we will reason well and thoroughly when thinking on our feet.  For example, we may be familiar with rotator cuff claims but may be faced with a claim involving an alleged SLAP lesion, with which we are considerably less familiar.  The claim’s relative novelty should not faze us if we have mastered the process of rational decision-making.  If we lack expertise, the process of analyzing, investigating, and judging will take more time than it otherwise would; however, the process itself should not be daunting because it should be the same regardless of our expertise.  Evidence and assumptions are subject to the same testing and analysis.  Our conclusions are evaluated in the same way to determine internal consistency.  We will need to learn what the rules governing the new problem are and how they are applied to particular cases.  Once we have this information, the actual decision-making process is the same regardless of whether we are familiar with the type of claim or not. 

Take the diagnosis of SLAP lesions.  Often a claim involving a SLAP lesion will be made based on MRI findings.  We have, for whatever reason, a tendency to reflexively accept MRI as being accurate diagnostically and as accurately establishing a causal link between a patient’s physical complaints and the findings on the scan.  In truth, MRIs are neither accurate in all instances nor can an MRI alone establish that the patient’s physical complaints are related to the findings on the scan.  For some orthopedic conditions, MRI is the diagnostic gold standard; however, for other orthopedic conditions MRI is not an effective diagnostic tool.  For example, studies have shown that MRI is more sensitive for diagnosing posterior collateral ligament (“PCL”) tears in the knee than arthroscopy because of the ligament’s anatomical position.  On the other hand, diagnosing SLAP lesions on MRI is exceedingly difficult with false positive rates of over 20% and false negative rates that can exceed 50%.   The American Academy of Orthopedic Surgeons reiterates that MRI is not considered reliable in diagnosing SLAP lesions:

Although other diagnostic tools—such as radiographs, computerized tomographic arthrography, and magnetic resonance imaging—are frequently used, the results are not considered reliable enough to make a definitive diagnosis of a SLAP tear.

Further, the Mayo Clinic reports that:

As imaging continues to improve and more people undergo MRI studies, physicians are finding that a significant percentage of people within the general population have labral changes that do not cause symptoms or need repair. In particular, there are age-related changes that can cause degenerative splits and tears in the labrum. While they may not be symptomatic, visually they can mimic a SLAP lesion. When these appear in MRI studies, misleading assumptions may be made between the images and the patient symptoms.

If we are self-conscious about our own thinking and reasoning, we will know that the first question we should be asking when we face a diagnostic imaging study, MRI or otherwise, with which we are unfamiliar (due to the body part or the actual test itself) is the rate of false positives and false negatives for the imaging test.  From there we will know that we should ask what is the diagnostic gold standard and how does the current test compare to other diagnostic techniques, including physical examination?  What does the medical community recognize as the definitive test or tests for establishing the diagnosis?  What is the consensus on the relationship between particular physical complaints and the findings on diagnostic imaging studies?  Before we accept test results or acquiesce to a request for testing, we will be able to determine if the results or a request are likely to be considered reasonable as a matter of medical necessity and whether we should be considering a second opinion record review (at the very least) to evaluate the results of the a request.

With respect to SLAP lesions, the increase in SLAP lesion repairs and the rather dismal success rate offers a good example of why adopting and adhering to a rational decision-making process is so important. Between 2004 and 2009, the rate of SLAP lesion repair increased 105% despite the fact that the incidence of SLAP lesions in the general population did not appear to increase.  This should give us pause to ask a few questions in keeping with our decision-making strategy.  First, was a diagnostic tool developed that demonstrated an increasing amount of symptomatic SLAP lesions in the general population?  Answer:  no.  Second, was a new surgical technique developed that allowed previously unrepairable, symptomatic SLAP lesions to be successfully repaired?  Answer:  no.  Third, was a surgical technique developed that greatly increased the rate at which SLAP lesions could be repaired successfully?  Answer:  no.  Fourth, was there a change in the general population that caused substantially more people to suffer from symptomatic SLAP lesions?  Answer:  no.  So why, then, are so many more surgeries to repair SLAP lesions being performed?  Perhaps there wouldn’t be such a precipitous increase if an internalized process of rational decision making were applied to these claims. 

Ultimately, using a rational decision making approach will cause us to get beyond the bias we have toward overweighting MRI findings and to develop a strategy for managing the claim based on fact as opposed to bias and assumption.  And when we do this, when we are self-conscious about our thinking and reasoning process, we will know that just because an MRI finds evidence of labral changes and an orthopedic surgeon says the employee needs surgery to repair the labrum doesn’t mean we should accept the findings or the recommendation at face value.  Instead, we will get a second opinion and potentially spare ourselves the cost of a surgery that is likely to be unnecessary and ineffective.  In the end, this is the essence of good decision making.  

3/25/2015 in Blog Categories, News

Risk Management Consultant Barry Thompson has an interesting post at his blog, www.claimanswer.com, in which he argues that all worker's compensation medical claims should be processed through Medicare from day one.  The gist of his argument is that:

1) It [processing worker's compensation medical claims through Medicare] provides a nationally accepted level of care to injured workers.

2) It brings clinical common sense to an otherwise specious and manipulated system.

3) It ends the oppressive impact of MSA’s.

4) It saves an incredible amount of direct costs, frictional costs and resources while reducing litigation.

To be clear, Thompson proposes that worker's compensation carriers would reimburse Medicare for claims deemed to be wholly or partially related to a work injury and that the indemnity system would remain intact.  It is his argument that Medicare has better, more uniform standards for assessing medical causation and is much better at keeping treatment costs under control.  Food for thought.

3/19/2015 in Blog Categories, News

Prescription pain medication overuse and abuse is and has been a national problem for many years now.  We have previously written about the issue in Second Opinions.  Among the common suggestions that experts make for curbing the problem are more stringent dosing guidelines, creation of and active prescriber participation in state prescription drug monitoring programs, and greater provider education about the problem.  Recent data from Washington State shows how effective these interventions can be.  Medical News Today reports on a study published in the American Journal of Public Health that while prescription opioid death rates have remained steady for the nation as a whole from 2008 to 2012, Washington State saw a 28% decline.  The article specifically notes that:

New state laws on prescription opioid use, including one that mandated the adoption of new dosing guidelines; a statewide Prescription Drug Monitoring Program; and telemedicine and on-line programs for health care providers have all been key to the turnaround.

Provider participation in telemedicine online programs was seen as a key factor in educating providers on appropriate dosing, medication changes, and dangerous drug interactions to avoid.  The electronic programs also have the advantage of allowing providers to discuss difficult cases with specialists to help craft solutions that avoid dangerous opioid use, decrease patient suffering, and preserve the doctor-patient relationship.

Here in the Midwest, we should demand that our clinicians, university medical centers, and legislators work together to craft an effective program to curb prescription pain medication overuse and abuse.  The Washington State example demonstrates that substantial, cost-effective improvement in prescription pain medication practices can be achieved when all concerned parties come to the table and work together.    And for those of us in the medico-legal world, curbing prescription pain medication overuse and abuse would be a welcome development in helping control the monetary and human costs of many claims.

Chronic pain devastates sufferers and those close to them.  When it arises in the context of a worker’s compensation or personal injury claim, chronic pain complicates claims management and invariably increases costs, making a satisfactory resolution to all parties difficult to achieve.  The most heartbreaking context in which chronic pain arises is, however, military veterans injured in combat.  Unfortunately, veterans returning from Iraq or Afghanistan suffer higher rates of chronic pain than veterans of any other U.S. Military conflict.  The good news is that the VA is aggressively researching the problem and recently made some headway (that could alter the standard treatment protocol for all chronic pain sufferers, regardless of etiology).

VA researchers published the results from the ESCAPE trial (which stands for “Evaluation of Stepped Care for Chronic Pain”) in which they found that a specialized stepped care program resulted in participants reporting a “decrease in pain severity and 30 percent improvement in pain-related disability.”  The results are significant because “we know that medications alone are only modestly successful in helping [chronic pain sufferers]” and that “current pain treatments haven’t made much of a dent,” according to Dr. Matthew Bair, who led the study.

The stepped program involved an initial 12 weeks of treatment with analgesic medication and self-management using such strategies as relaxation techniques.  The second step involved 12 weeks of cognitive behavioral therapy.  The second step helped participants “counter maladaptive thought” and to learn what activities they could substitute for pre-deployment activities to decrease pain and remain physically active.  This second phase would seem critical in the claims context where the greatest challenge is often simply overcoming the disability mindset, or turning the ingrained and almost pathological attitude of “I can’t” to “I can.”  In many cases, the issue is not that the chronic pain sufferer cannot perform an activity so much as it is that they convince themselves that they cannot before even attempting the activity.  The exciting thing about the study results and using targeted cognitive behavioral therapy in general is that it can help reorient the way chronic pain sufferers view activity in general.  Just because an injured worker can no longer train for and participate in marathons due to chronic low back pain does not mean that she cannot complete an 8-hour day as a delivery driver.  If cognitive behavioral therapy can help chronic pain sufferers to start looking at the world from the psychological perspective of “I can,” it would seem to go a long way toward improving both the lives of chronic pain sufferers and the outcomes of chronic pain claims.

The ESCAPE study is an exciting development in managing chronic pain patients.  Given the difficulty of managing chronic pain claims and the explosion in prescription opioid drug abuse related to treatment of chronic pain, it will be worth following the ESCAPE study to see if its results can be replicated.  Even a 30 percent reduction in disability level would likely be significant in a chronic pain claim and could easily represent the difference between partial impairment (and a return to work) and total disability.

Perhaps the most difficult challenge in orthopedics is articular cartilage.  You know, the white, pearlescent stuff that covers our joints and makes them operate smoothly and without pain (before arthritis sets in, that is).  And why is articular cartilage so difficult?  Well, it’s pretty simple:  we can’t regrow it when it breaks down and wears away.  Hence, the only options for treating worn articular cartilage or osteoarthritis are, once the pain and dysfunction become unbearable, to fuse the worn joint or to replace it with artificial components.  Despite advances in orthopedic components and surgical techniques, joint replacement is a suboptimal option for treating worn articular cartilage.  Fusion is even less optimal, the point of joints being articulation (or motion).

If we could figure out a way to regrow articular cartilage, calling it game-changing would be an understatement.  It would be revolutionary, especially for those in the worker’s compensation world where countless musculoskeletal injury claims involve allegations that work injuries or occupational exposure caused or worsened osteoarthritis.  Can you imagine a world where a claimant with debilitating knee pain goes to the doctor and rather than walking out with a knee replacement, the claimant goes to a gene therapist who treats the knee by growing new articular cartilage?  No surgery, no infection, no rehab, no disability, just a new knee. 

Turns out this dream is closer to reality than you might think.  Researchers in Manchester, England recently published research in which they used embryonic stem cells to regrow articular cartilage in the damaged knee joints of rats.  Remarkably, "[a]fter 12 weeks, the cartilage surface was smooth and similar in appearance to normal cartilage.”  In contrast to earlier efforts which produced abnormal and disorganized tissue, including tumors, the Manchester scientists were able to grow wholly normal, functioning cartilage in the rats’ knee joints.

These findings from the Manchester study are exciting (almost beyond exciting, truth be told).  The research is worth monitoring as it advances toward testing in human subjects, which is still probably several years away.  Nevertheless, this development gives us a glimpse of a potentially arthritis-free future.  Imagine that.

2/20/2015 in Blog Categories, News

Test your own line of reasoning for internal consistency.

Much of the point of Brewer’s preceding rules or decision heuristics was to remove assumptions and emotion out of the claims evaluation process.  This step is where we put the prior steps to work for us to evaluate whether we have in fact successfully analyzed the claim before us in an unbiased and logical fashion. 

Let us assume that we are analyzing a claim involving an acute foot injury followed by years of occupational exposure in an obese, 46-year-old, female claimant.  When the claimant was 37, she suffered a calcaneal fracture while on the job.  She is employed as an assembler doing light work, but stands for the duration of her shift.  She was not issued final restrictions after reaching an end of healing following the first injury, but was issued a 15% PPD rating based on loss of motion.  The employer did not offer any accommodations to limit the amount of standing the claimant would have to do, but the claimant never requested an accommodation or complained about standing too much.  The claimant subsequently developed arthritis and is scheduled to undergo a subtalar fusion.  Medical opinions support three possible causes for the claimant’s current condition and the need for the fusion:

  1. The arthritis is related to the claimant’s age and body habitus and bears no relationship to the calcaneal fracture or the subsequent workplace exposure;
  2. The arthritis is wholly related to the calcaneal fracture, is a normal sequelae of that type of injury, and the subsequent occupational exposure was not a material contributory causative factor in the onset or progression of the arthritis;
  3. The arthritis is posttraumatic and the subsequent occupational exposure was a material contributory causative factor in the progression of the arthritis (causing it to progress faster than it otherwise would have).

In our case, we represent the carrier on the risk for the subsequent occupational exposure date of injury.  Our IME doctor concluded that the claimant developed the arthritis due to her age and weight and supports his conclusion by arguing that the claimant would have become symptomatic much sooner if the arthritis were posttraumatic.  The IME doctor for the carrier on the risk for the acute fracture date of injury concluded that the arthritis is posttraumatic but that the subsequent period of occupational exposure caused the arthritis to progress faster than it otherwise would have.  Finally, the treating surgeon concluded that the acute fracture is the sole cause of the arthritis and the need for the surgery. 

During the course of our investigation we learned several things:

  1. The claimant’s non-injured foot is asymptomatic;
  2. The claimant dislocated the same ankle while sliding into third base during a high school softball game when she was 16.  The dislocated ankle was manually reduced and treated non-surgically with casting then physical therapy;
  3. The claimant works from 7:00 to 3:30 and has two 15 minute breaks and a 30 minute lunch.  The employer admits that generally the claimant and other assemblers stand for the balance of each day unless they are in a meeting.  Production meetings are held Mondays at 7:00 and last 15-20 minutes.  Otherwise assemblers are infrequently in meeting (less than once per month). 
  4. 9 months before the occupational date of injury the employer hired a new production supervisor.  In general, the assemblers do not like the new supervisor and several, including the claimant, complained to human resources about his conduct. 
  5. The calcaneal fracture and the current subtalar fusion are the only worker’s compensation claims the claimant has made.
  6. Both insurance carriers took recorded statements and the claimant consistently describes the injury occurring gradually, over a period of a few months, progression until it became too painful to ignore at which time she sought treatment with the orthopedist who treated her original fracture.
  7. The original calcaneal fracture was displaced and treated surgically with open reduction and internal fixation.
  8. The claimant reported that she does not wear high heels or other non-supporting shoes but instead generally wears running shoes when she is not a work.

Based on the information obtained in the investigation, we developed a litigation plan and completed our investigation.  Now we have our litigation plan in place and are preparing to roundtable the claim with our supervisor.  Before heading to the roundtable, we have decided to run through the claim again to judge whether we are still comfortable enough with our analysis to present and defend it at the claims roundtable.

We reached the following conclusions about the claim:

  1. An ALJ is likely to find the current condition to be work-related because the uninjured ankle is asymptomatic.
  2. An ALJ is more likely to find the original fracture is the appropriate date of injury than the occupational exposure date because the treating orthopedist on both injuries concluded the subsequent occupational exposure did not cause the onset or progression of the condition.

To prepare, we need to analyze our conclusions to see if they are internally consistent.  First, we concluded that the injury is likely to be deemed work-related.  In examining the claims file, two strong facts support our conclusion.  One, the employee’s uninjured foot shows no evidence of arthritis.  This is significant because the claimant’s occupation stresses the subtalar joints of both feet equally (or nearly so).  Hence, if the arthritis were idiopathic we would expect to see the arthritis in both subtalar joints.  Two, subtalar arthritis is a well-known and relatively common complication of calcaneal fractures.

Second, we concluded that the ALJ is more likely to conclude that the original fracture is the appropriate date of injury for the claimant’s current condition.  Our basis for concluding this is that the treating physician who treated the original injury and the current condition is the same; therefore, he has had the best chance to observe the claimant over time which renders his opinion most credible.  This is not as solid a position as the first one is.  In a sense, the argument is a non sequitur because it does not necessarily logically follow that the treating physician is better able to determine causation based on familiarity with employee’s condition over time.  In making this argument, we have at least one unstated premise that needs to be articulated and explored before we can determine if the argument is in fact internally consistent and valid.  The unspoken premise is a common one in worker’s compensation:  all things being equal, ALJs consider treating physicians to be more credible than IME physicians.  As far as I know, this assumption is based on experience and anecdote and not actual objective data.  Hence, we need to be cautious in applying the assumption to our argument and should not consider it necessarily to be dispositive.  The reason for our caution is that the assumption is based on the overarching view that most ALJs will, all things being equal, apply the Worker’s Compensation Act liberally and grant benefits to employees making claims.  If this view is true, and at least it is reinforced by statute and state Supreme Court pronouncements, then it actually may weaken our assumption that an ALJ will find the treating physician most credible in this case.  The reason is that if an ALJ were to find the treating physician most credible, the employee would be stuck with benefits at a considerably lower rate than if the ALJ found the IME doctor for the original date of injury to be most credible.  Remember:  the IME doctor for the original date of injury insurance carrier finds the claim is work-related and his opinion establishes a date of injury 9 years later, with the corresponding increase in the temporary total disability and permanent partial disability rates that would obtain.  If the primary motivating factor of an ALJ in a close case is giving benefits to a claimant then it is reasonable to assume that the ALJ will also be motivated to give a claimant the highest benefit rate when there is a credible opinion allowing her to do so.  Thus, we may wish to adjust our opinion and note that the date of injury is likely to be a closer call than we at first posited.

Obviously this is simplistic and something of an exaggeration intended for illustrative purposes.  Presumably, we would have considered the problematic assumptions about the date of injury as soon as we had all the relevant medical opinions.  Nevertheless, the example serves a purpose:  when evaluating a claim, you must test the line of reasons that led you to the conclusions you reached for internal consistency.  In doing so, you will stand the best chance of discovering non sequiturs and other logical reasoning problems or errors that may cast doubt on the validity and strength of the conclusions you reached.

Reason #1:  Employers shall not use doctors “employed on a regular basis by the employer” when seeking FMLA second opinions.  We have a large number of doctors to choose from and can track how many times you have used the same doctor. 

Medical Systems, Inc., we’re not just for worker’s compensation any more.

2/10/2015 in Blog Categories, News

The University of Texas Southwestern Medical Center released information critical to the success of cardiopulmonary resuscitation (more commonly referred to as “CPR”) efforts.  Specifically, medical researchers reviewed research and found that persons applying chest compressions to those in cardiac arrest often compress the chest too deeply and too rapidly.  Researchers say there is a “sweet spot” between the depth of compressions and the rate of compressions that optimizes the chances for a patient’s survival.  For chest compressions to have the best chance of working, they need to be performed to a depth of between 5 and 5.5 centimeters (about two inches) and at a rate of between 100-120 compressions per minute.  The researchers found that compressing the chest greater than 5.5 inches reduces the likelihood of survival and speculate that such deep compressions probably cause injury to the patient which counteracts the resuscitative effects.  In addition, researchers found that many responders perform chest compressions at rates of about 140 compressions per minute, which is too fast and reduces the effectiveness of the resuscitation attempt.  To achieve the right rate of compression, researchers noted that timing the compressions to the beat of “Row, Row, Row Your Boat” is effective and used by many well-trained first responders.

First responders and others trained in CPR should be aware of this new information.  Chest compressions that are too soft are ineffective as are compressions that are too hard.  Ditto compressions that are too slow or too fast.  Instead, chest compressions need to be just right. Apparently Goldilocks was on to something.

Medical News Today reports on a significant new study (fee or subscription required) of what causes episodes of acute low back pain.  Critically, the study’s authors concluded that most physical and psychosocial triggers of acute low back pain can be modified.  Per Medical News Today, some of the findings include:

  • [C]arrying out manual tasks involving awkward postures increases the risk of triggering acute low back pain by eight times;
  • [F]atigue and being distracted can also significantly increase the risk of acute low back pain;
  • [T]he odds of a new back pain episode was nearly 3 times higher chance following moderate to vigorous physical activity; and
  • [T]he odds of a new back pain episode was to a 25 times higher chance after being distracted during an activity.

Unusually, the study “also found that age was a factor in triggering back pain when lifting heavy loads - with younger people being significantly more likely to suffer an episode of acute low back pain after such activity than older people.”  This certainly will be counterintuitive for claims administrators and attorneys in the worker’s compensation field as conventional wisdom suggests older age is directly proportional to low back injuries rather than the inverse as was found in the study.  Regardless, the most important thing is to utilize knowledge from the study to reduce episodes of acute low back pain in the workplace.  Manuela Ferreira, lead author stated the matter succinctly:

Our findings enhance knowledge of low back pain triggers and will assist the development of new prevention programs that can reduce suffering from this potentially disabling condition.

What is it about shoulders?  They seem to cause an inordinate amount of problems, especially when the rotator cuff is involved.  And invariably, there is a question as to whether a shoulder claim involves an acute injury, an acute aggravation of a preexisting condition, an occupational injury, or the mere manifestation of a preexisting condition.  One of the biggest challenges in claims is determining whether and to what extent a shoulder condition is work-related.  Unfortunately, this task is often difficult for physicians too.

The hallmark of an acute rotator cuff injury is an asymptomatic shoulder, a discernible traumatic event, and immediate pain and weakness.  Unfortunately, this type of presentation accounts for less than 10% of all rotator cuff tears according to some literature.  In addition, the medical literature suggests that acute rotator cuff tears are underdiagnosed in emergency departments and often attributed to tendonitis, bursitis, arthritis, or some combination of all three.  To further complicate matters, many other conditions of the shoulder, cervical spine, and peripheral nerve system can produce symptoms that are similar to symptoms occurring in rotator cuff tears.  And finally, a somewhat sizable percentage of the population has asymptomatic rotator cuff tears which makes the determination of the etiology of the cuff defect difficult to determine.

The best way to assess whether a rotator cuff tear is acute or traumatic is with diagnostic imaging.  Numerous studies have found that mid-substance tears are more likely to be acute than insertional tears.  The presence of swelling and joint fluid or a hematoma also suggest that a tear is acute.  To the contrary, the absence of joint and bursal fluid suggests a chronic tear.  The presence of fatty infiltration and the degree of rotator cuff atrophy are also useful findings to assess the chronicity of the tear.  Interestingly, at least one study found that the “injury mechanism and the activity at the moment of injury did not correlate with the presence of a rotator cuff lesion,” but also found “a strong age correlation, with a prevalence of RCTs above 50% in patients aged over 50 years…” This study suggests a shockingly high rate of rotator cuff injury resulting from shoulder trauma in persons over 50. 

The strong correlation between age and rotator cuff tear caused one study’s authors to postulate that “it is even likely that there [is] no such thing as an acute cuff tear without some previous tendon degeneration.”  The authors of another study address the complicated relationship between the chronicity and symptomatic nature of rotator cuff tears and note that the “duration of symptoms does not necessarily reflect the duration a patient has had a rotator cuff tear…  It is not understood why full-thickness tears become symptomatic in some individuals and not others.”  How then, can any physician determine to a reasonable degree of medical certainty if a particular rotator cuff tear relates to the patient’s employment in the absence of diagnostic imaging that suggests a tear is acute?

In truth, the answer is that any physician who attributes a symptomatic rotator cuff tear to a workplace injury is most likely engaging in speculation if there is no acute traumatic event and no diagnostic imaging evidence demonstrating that the tear is acute.  This doesn’t mean that the tear can’t be acute and work-related, simply that there is no reasonable basis for a physician to determine the exact etiology of the tear to a reasonable degree of medical certainty.  In handling claims, it is important to recognize these situations and pose the question to the IME doctor directly as to there is any way, given the current state of evidence-based medicine, to determine what caused a rotator cuff tear (or caused it to become symptomatic) to a reasonable degree of medical certainty in the absence of an acute traumatic event, diagnostic imaging evidence that a tear is acute, or occupational risk factors such as repetitive overhead work.  If there are no specific risk factors, no precipitating injury, and no diagnostic imaging evidence of an acute tear, the answer should always be “no.”

From a claims perspective, there are several useful things that can be gleaned from the medical literature addressing rotator cuff conditions.  First, a definitive assessment of causation in the absence of a discrete, acute precipitating event with imaging evidence demonstrating the presence of an acute tear or an occupational risk factor should be considered impossible.  Of course treating surgeons will attempt to relate rotator cuff conditions to workplace injuries that do not meet the above criteria, but it is incumbent from a claims perspective that the IME physician points to the relevant medical literature and explains why it is not possible, to a reasonable degree of medical certainty, to determine the etiology of a rotator cuff tear in the absence of the above criteria. 

Second, it should not come as a surprise if an employee over 40 who says they hurt their shoulder and is told that it is just a strain or tendinitis when they go the ER later discovers she has a rotator cuff tear.  The medical literature suggests that clinical examination in the emergency setting underestimate the presence of rotator cuff tears.  The relevant study found that in the patient population complaining of an acute shoulder injury who have an inability to perform active abduction above 90° and normal radiographs, more than 50% will have rotator cuff tears.  In establishing reserves, if the medical records show normal radiographs coupled with an inability to actively abduct the shoulder above 90°, it may be wise to consider the likelihood of a rotator cuff tear requiring surgical intervention to be 50%. 

Finally, knowing the different shoulder, neck, and peripheral nerve conditions that have similar symptom constellations to rotator cuff tear will help to assess what the likely diagnosis will be based on the clinical history, examination, and positive findings.  Thus, a shoulder complaint that can be localized to the acromioclavicular joint, is more likely to be a shoulder separation or acromioclavicular arthritis than a rotator cuff tear.  In another example, a complaint of gradual onset of shoulder pain with weakness that is especially noticeable during sleeping hours is likely to be a chronic rotator cuff tear or advanced impingement syndrome than an acute rotator cuff injury.

The bottom line is that shoulder injuries are often difficult claims, especially when they involve rotator cuffs.  Knowing the medical literature about how rotator cuff tears occur and what suggests acute versus chronic tears can help guide the claims analysis.  To learn more about the diagnosis, management, and prognosis of rotator cuff tears, join us on February 26, 2015 for the Medical Systems Advanced Medical Topics in Worker’s Compensation in Brookfield, Wisconsin at which Dr. Bartlett will give an in-depth presentation on acute shoulder injuries.  Claim handlers and legal professionals alike will gain valuable information on what claims will likely be compensable and what medical information can be used to defend against those which should not be compensable.

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