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Surveillance can be a good way to move a case to closure.  The success of the investigation depends on both the adjuster and the investigator’s ability to gather accurate and reliable information.  Arm your investigator with as much information as you can provide.  Here are some tips to assure effective surveillance:

  • Select an investigation company that has experienced investigators with a proven success record.   
  • Before the investigation begins, conduct a Social Security trace, ANI trace and social media check.  Make sure these findings are communicated to the investigator.
  • Start off with two full days of surveillance starting at 6:30AM.  Based on the results after two days, decide whether further time is warranted.
  • Always have surveillance conducted on days when the claimant has a medical appointment.

For every 6 million occupants in Low Speed Rear Impact Collisions: 

  • About 3 million will be injured (about the population size of South Carolina).
  • About 1.5 million will have chronic pain (about the population size of Nebraska).
  • About 300,000 of these become disabled usually due to pain (about the population size of Wyoming).
  • Nearly half of all chronic neck pain in America is due to car crashes—mostly Low Speed Rear Impact collisions. 
  • About 9% of all Americans suffer from chronic neck pain due to Low Speed Rear Impact Collisions. 
  • Children are at 2/3 the risk of adults.

Information provided by the Spine Research Institute of San Diego

Tarsal Tunnel Syndrome is to the foot and ankle as what carpal tunnel syndrome is to the wrist and hand.  Tarsal Tunnel Syndrome occurs when the posterior tibial nerve (running along the ankle and foot) becomes compressed or damaged, causing inflammation of the tarsal tunnel.  This condition results from prolonged walking, running, standing or exercising, traumatic injury, or no apparent reason. 

Often Tarsal Tunnel Syndrome responds well to conservative treatment.  With the goal of treatment being to reduce inflammation and pain, rest, ice, compression and elevation are often recommended along with the use of over-the-counter non-steroidal anti-inflammatory medications (acetaminophen or ibuprofen).  If this is not effective, injection therapy using corticosteroids and local anesthetics can be tried.  Orthopedic devices and corrective shoes may assist in reducing foot pressure.  Exercises learned in physical therapy can help reduce symptoms by stretching and strengthening connective tissues and mobilizing the tibial nerve and opening surrounding joint space reducing compression. 

Surgery can be performed for severe or chronic cases that do not respond to any other forms of treatment.  The procedure releases (or decompresses) the tarsal tunnel with a recovery period of 6 weeks up to several months.  Surgery is successful in about 50%-90% of cases.

Fortunately, tarsal tunnel syndrome is a rare disorder.

There are several areas of research that may prove successful; stem cell injections, a Collagen Meniscal Implant (CMI), and 3-D research.

In a clinical trial of stem cell injections for meniscal tears, only 15% of participants experienced an increase in meniscal tissue at one year following treatment.  This could be because without healthy cartilage to pad the bones that meet in the knee joint, the bones become battered and misshapen and a new meniscus can’t fix that damage.  So, it would make sense to try stem cell medicine on people with new injuries who do not have the damage to their bones.

The Collagen Meniscal Implant, a biological completely absorbable implant made from highly purified collagen with a porous structure showed some promise.  This device is attached arthroscopically to fill the void resulting for damaged or lost meniscal tissue and makes use of the body’s own ability to re-populate the structure with its own cells over time to regenerate the normal structure of the meniscus.  There is data showing benefit in chronic meniscal injuries for the right patient.

In a study successfully conducted on sheep, a meniscus was regenerated with a 3-D printer, infused with human growth factors that prompt the body to regenerate the lining on its own. It begins with MRI scans of the intact meniscus in the undamaged knee.  The scans are converted into a 3-D image which is used to drive a 3-D printer.  A scaffold in the exact shape of the meniscus down to a resolution of 10 microns (less than the width of a human hair) is produced within 30 minutes.  This research is preliminary but it demonstrates potential for meniscus regeneration.

However, the reality is at present there’s little that orthopedists can do to regenerate a torn knee meniscus.  Small tears can be sewn back in place, but larger tears have to be surgically removed which helps with pain and swelling, but leaves the knee without its natural shock absorber.  There are three viable options on the horizon, but they are still in the research stages and it could be years before they are offered to the general population.

The best way to obtain a good recorded statement is to have a predetermined process for planning and preparation of the interview.  Here are some tips to conduct a thorough interview:

  • Be a Good Listener – Thoroughly listen to what is being said, do not think about your next question or what you’re going to say next.  Clear your head and simply listen to what is being said.  You may pick up on new information that would otherwise not be communicated.
  • Standard Questions – These should be predetermined by insurance company protocol and based on the type of insurance coverage and injury.
  • Focus Questions – In advance of the interview, review all information available and prepare a list of questions that focus on the specific injury and how it occurred.
  • Flexibility – Be ready to take the interview in a different direction depending upon the answers to standard and focus questions. 

The success of the investigation depends on the adjuster’s ability to gather accurate and reliable information.

11/1/2018 in Medical Conditions

The anterior cruciate ligament (ACL) can be injured as a result of getting hit very hard on the side of the knee, overextend injury to the knee, or landing from a jump incorrectly.  Symptoms include a “popping” sound heard at time of injury, swelling within 6 hours, and pain.  A mild injury may only result in a feeling of instability of the knee or it seems to “give way” when using it.

ACL injury can sometimes be diagnosed during a physical exam alone, but diagnostic testing may be required to rule out other causes and determine the severity of the injury.  Tests could include x-rays, magnetic resonance imaging (MRI), and/or ultrasound.

Initial treatment is aimed at reducing pain and swelling, with rest, ice, compression and elevation.  Several weeks of rehabilitation can be expected, with a physical therapist initially teaching exercises which can be performed with continued supervision and/or at home.  A brace can stabilize the knee and possible crutches to avoid weight bearing.  The goal is to restore full range of motion and strengthen the knee.

Surgical repair could be recommended if more than one ligament or the cartilage of the knee is injured, the claimant is young and active, and/or the injury is causing the knee to buckle.  The procedure, an ACL reconstruction, involves removing damaged ligaments and replacing with a segment of tendon.  After surgery, rehabilitation takes place to restore strength, stability and function to the knee.

There is a revolutionary new procedure, called BEAR (Bridge-Enhanced ACL Repair) that is currently in testing stages.  A “bridge” is surgically inserted into the ACL which allows the ACL ends to heal back together themselves.  So far, the procedure when tested in pigs showed significantly less arthritis (a complication of ACL injuries).  Three months after surgery on the first human trials, all BEAR recipients had healing ACLs, flexibility close to that of the healthy knee, and recovered strength more quickly than the traditional ACL repair.  While more testing is needed, this new procedure appears to show extreme promise.


10/25/2018 in Medical Conditions

Meniscus tears are one of the most common knee injuries.  That’s because an athlete, an older person and anyone in between can tear a meniscus. 

They can be torn in different ways.  Tears are described by how they look as well as where the tear occurs.  Common tears include bucket handle, flap and radial.  Sports related tears often include more than just the meniscus (such as an anterior cruciate ligament tear). 

A meniscus tear is diagnosed by obtaining a medical history, discussing symptoms, and examination of the knee.  One of the main tests for meniscus tears is the McMurray test.  The doctor bends the knee, straightens it and then rotates it.  This puts tension on a torn meniscus and will cause a clicking sound.  Imaging tests, such as x-ray or MRI may be ordered as well.

Treatment depends on the type of tear, size and location.  The outside one-third of the meniscus has a rich blood supply which may allow it to heal on its own.  The inner two-thirds of the meniscus lacks a blood supply which does not allow it to heal.  These are complex tears which often occur in thin, worn cartilage.  These types of tears usually require surgery.

Without treatment a piece of meniscus may come loose and drift into the joint.  This can cause the knee to slip, pop or lock.

Since meniscus tears are extremely common knee injuries, proper diagnosis, treatment and rehabilitation often returns patients to their pre-injury abilities.

10/23/2018 in Medical Conditions

Plantar fasciitis is one of the most common causes of heel pain.  It occurs when the thick band of tissue that runs across the bottom of the foot and connects the heel bone to the toes gets inflamed.  Symptoms include a stabbing pain at the bottom of the foot near the heel.  It generally occurs when you haven’t walked for a while, such as first thing in the morning.  As more movement of the foot occurs through walking the pain normally decreases but could return after long periods of standing or upon rising from a seated position.  

Plantar fasciitis is common in persons between the ages of 40-60 but can be brought about at any age with certain types of exercise, such as running, jumping, ballet dancing, aerobic dance.  Plantar fasciitis can also be the result of anatomic deviations from normal, such as being flat footed, a high arch, or an abnormal walking pattern.  Obesity is also known to put extra stress on the plantar fascia.  Occupations which involve mostly standing can also damage the plantar fascia leading to plantar fasciitis.

Plantar Fasciitis is tough to treat.  Often times treatment takes several months.  Rest, ice, and Nonsteroidal anti-inflammatory drugs (NSAIDs) can help reduce inflammation and pain.  If pain isn’t responding to NSAIDs, a steroid injection can ease pain for about a month and will keep inflammation down for even longer.  Physical therapy might be recommended if none of the other modes of treatment worked.  From this point forward, treatment gets more aggressive.

Shock-wave therapy, where sound waves literally “shock” the plantar fascia to stimulate blood flow and help tissue to heal; pain is stopped from the stunning affect it has on the nerves.

Tenex procedure, like an “arthroscopy” of the foot there is a small incision and an ultrasound is used to target and remove scar tissue.  Life gets back to normal in as little as 10 days.

The last resort is surgery, where the plantar fascia is removed from the heal bone.  Although this can be done as an outpatient, healing takes longer with the use of a splint or boot and no weight bearing, then limited weight bearing and things will hopefully progress to unrestricted weight bearing.

Plantar fasciitis is a common condition that is difficult to treat and can have a long healing period.  Time away from work can easily cost employers thousands in lost time and treatment bills for just one employee.  Encouraging healthy habits can lessen the incidence of plantar fasciitis in the workplace, which in turn can lower the cost of lost time and treatment.  Examples of healthy practices include: 

  • Exercises to help prevent plantar fasciitis
  • Incentives for the purchase of good quality shoes
  • Incentives for losing weight or maintaining a healthy weight (many group health insurance companies offer incentives to employees for healthy habits)
  • Allowing frequent breaks to sit or provide a chair (when possible) so employees can decide how they are best comfortable
  • If it is not possible for the employee to sit, perhaps a cushioned mat could be a solution

Proactive involvement in prevention can cost little as compared to what it saves.

10/11/2018 in Medical Conditions

The meniscus is often described as the knee’s “shock absorbers.”  That’s because they are a piece of cartilage providing a cushion between the thigh bone (femur) and shin bone (tibia).  Each knee joint has two menisci.  Their purpose is to help equally distribute the body’s weight, protecting and extending the life surrounding cartilage. 

 A meniscus can be torn or damaged during any activity that puts pressure on or rotates the knee joint.  Younger people are likely to experience sports related traumatic tears.  However, as a person ages, the cartilage in the knee becomes weaker and thinner, and is more prone to tears from simple activities of daily living.

Generally, when a meniscus tear occurs, a popping sound is heard around the knee joint.  Afterwards, many people experience pain (especially when the area is touched), swelling, difficulty moving the knee or inability to fully move it, a feeling of the knee locking or catching, and a feeling the knee is giving way or unable to support you.

Meniscus tears are actually quite common.  In fact, about 700,000 Americans undergo a meniscectomy (meniscus surgery) annually.  Many others have the condition and choose not to move forward with surgery.  Decades ago the entire meniscus was removed on the belief that it would grow back, and when it didn’t a total replacement was undertaken. 

Today, the standard approach is to remove only the torn section of the meniscus through a partial meniscectomy and leave the healthy tissue.  The arthroscopic surgery is performed through two small incisions on the knee.

There have been many advances in technology which have progressed to a less invasive surgery resulting in quicker recovery time.  However, even with today’s advances, the symptoms go away and the patient has 5-10 years of relief, but the loss of even part of the meniscus can accelerate the onset of arthritis.

A new development of a tissue-engineered meniscus replacement has been announced. It consists of a biodegradable polymer that has been submerged in collagen and hyaluronic acid and weaved into the shape of a meniscus.  The sponge-like device is inserted into the knee where it fully dissolves and stimulates the body to rebuild new meniscal tissue naturally. 

The dissolvable polymer is strong enough to bear the pressure between the two bones while stimulating the body to grow a new meniscus in its place.  The new meniscus is not comprised of scar tissue – rather it is neo-meniscal tissue.  For many people with meniscal injuries this would eliminate the need for a future knee replacement.

This technology, which will be marketed under the name “MeniscoFix” is not yet available to the general public.  It is scheduled for clinical trials in the next two years and will be commercially available within 5-7 years. This new technology will allow doctors to tailor treatment to the patient’s specific type of tear and employ the least invasive method for the best outcome.


In order to resolve claims quickly and cost-effectively, it is necessary to recognize red flags, pre-existing conditions such as health concerns and degenerative issues at the onset.  This allows you to determine what tools are necessary to move the claim to closure.

  • Maintaining Communication – As soon as possible, establish contact with both the insured and the claimant.  Thoroughly listen to what is being said, do not think about your next question or what you’re going to say next.  Clear your head and simply listen to what is being said.  You may pick up on new information that would otherwise not be communicated.
  • Monitor Treatment – Make sure the claimant is compliant and that treatment hasn’t exceeded guidelines for the injury.  Get an IME if necessary.
  • Stay on Top of Litigated Claims – Make sure your defense attorney is keeping things moving forward.   

The single most important key factor in keeping claims moving forward is communication, with the claimant, insured, treating doctor(s), and if appropriate your defense attorney.  

9/27/2018 in Medical Conditions

The condition is characterized by persistent burning or aching pain with increased or decreased sweating, swelling, changes to skin color, damage to the skin, hair loss, cracked or thickened nails, muscle wasting and weakness, and/or bone loss.  As a result of pain, use of the affected area is limited which can produce stiff and shortened muscles, limiting range of motion.  CRPS is believed to be caused by damage or malfunction of the peripheral and central nervous systems.

The condition is often diagnosed following a forceful trauma to an arm, for example a crushing injury, fracture or amputation.  However, surgical procedures of the shoulder, carpal tunnel, and Dupuytren’s contracture have been known to manifest Complex Regional Pain Syndrome.   

There are two types of Complex Regional Pain Syndrome:

Type 1 – (used to be called reflex sympathetic dystrophy) refers to injury to tissues other than nerve tissue, for example when a bone is crushed in an accident.  It is thought that 90% of persons with complex regional pain syndrome have Type 1.

Type 2 – (used to be called Causalgia) refers to injury of nerve tissue.

There are several different types of treatment available and every person’s response to treatment is different.  Most treatment is geared toward keeping blood flowing to the painful limb and controlling the pain.  The prognosis of CRPS is highly variable.  Younger persons, children and teenagers have better outcomes, older people can have a good outcome as well.  However, there are some individuals who experience severe pain and disability despite treatment. 

Research has shown that CRPS-related inflammation is caused by the body’s own immune response.  Researchers are working to better understand how CRPS develops, what causes it, how it progresses, and the role of early treatment. 

9/20/2018 in Medical Conditions

Tendons take a long time to heal, so treatment is generally directed at speeding up the body’s natural healing process.  The following at-home treatments are often recommended:

  • Resting the tendon and avoiding repetitive movements. This may include taking a break every 15 minutes when doing repetitive activities, such as typing.
  • Stretching the tendon to increase its range of movement and flexibility and to promote circulation.
  • Massaging the affected area to promote circulation.
  • Strengthening the muscles around the tendon with exercises to reduce daily strain on the injured tendon.
  • Using braces or tape to protect the tendon from further injury.

Research has shown that vitamin C and curcumin supplements may help promote collagen production and speed up healing.

The following treatments may also be recommended:

  • Extracorporeal shockwave therapy (EWST), which involves applying pressure waves to the surface of the skin. This may promote the regeneration of tissue and speed up the healing process. EWST has been shown to be effective for some lower limb conditions.
  • Surgery can remove damaged tissue to relieve pain and allow the tendon to heal.
  • Corticosteroid injections around the tendon can reduce short-term pain and swelling. However, they may also make relapse more likely and can sometimes impair collagen production.
  • Platelet-rich plasma (PRP) injections, involve injecting plasma from the person's blood into areas around the tendon. The platelets promote cell repair and healing.

Anti-inflammatories and ice can help relieve the pain which is caused by inflammation.

The long-term outlook is good.  80% of tendinosis sufferers make a full recovery in 3-6 months.  If left untreated, tendinosis can lead to ruptured tendons so early treatment is important. 


9/13/2018 in Medical Conditions

A tendon is tissue that attaches muscle to bone.  It is flexible, tough, fibrous, and can withstand tension.  Tendons and muscles work together and exert a pulling force.  Tendons and ligaments are tough and fibrous, but they are known as soft tissue because they are soft compared with bone.

When a tendon is inflamed or irritated, it is referred to as Tendinitis.   Symptoms include pain (often described as a dull ache), which is increased when moving the affected joint, tenderness and mild swelling.  Different types of tendinitis affect different parts of the body, but for purposes of this blog we will focus on the upper extremities:

Supraspinatus tendinitis refers to inflammation of the tendon at the top of the shoulder joint causing pain when the arm is moved, especially upwards.  It may be painful to lie on the affected shoulder.  If other tendons in the same area are also affected, the diagnosis may be rotator cuff syndrome.

Tennis elbow otherwise known as lateral epicondylitis refers to pain on the outer side of the elbow which may radiate down towards the wrist. 

Golfer’s elbow, referred to as medial epicondylitis is pain on the inner side of the elbow which is more acute when trying to lift against a force and the pain may radiate down to the wrist.

De Quervain’s stenosing tenosynovitis is an inflammation of the sheath that surrounds the thumb tendons between the thumb and wrist.  The sheath thickens and swells, making it painful to move the thumb.

Trigger finger or thumb results in a clicking when straightening out the finger or thumb and becomes fixed in a bent position because the tendon sheath in the palm of the hand is thickened and inflamed.

Tendinitis of the wrist (or tendinopathy) mostly affects badminton players and production line workers who repeatedly use the same motion of the wrist.  This is a degenerative condition rather than an inflammation.

Tendinitis mostly arises from the repetition of a particular movement over time as opposed to a sudden injury.  For example, an occupation, hobby or sport that involve repetitive motions which puts stress on the tendons.  Age also increases the risk because as people age, their tendons become less flexible and easier to injure.

Most of the time tendinitis can be successfully treated with rest, physical therapy and medications (for pain reduction).  A full recovery can generally be expected within about six weeks.  However, if treatment is not successful and tendon irritation persists for several weeks or months, chronic tendinitis or tendinosis may develop. 

Often tendinosis is mistaken for tendinitis.  Tendinosis is a chronic injury which involves degenerative changes of tendon tissue and may also involve some inflammation.  Tendinosis is a long term chronic condition which can take 3-6 months to heal. 

So, in summary, there are many types of tendonitis which with proper rest and care can heal within about six weeks.  If not taken care of, tendonitis can turn into tendinosis which is chronic in nature and takes anywhere from 3-6 months to heal.

8/23/2018 in Medical Conditions

A physical examination by a physician consists of observation to look for deformities, muscle wasting, and changes in appearance of the damaged shoulder compared to the normal one. 

Palpation, or feeling the bones that make up the shoulder joint as well as the shoulder joint itself.  Further evaluation might include assessment of range of motion of both shoulders, strength testing, pressing on different parts of the shoulder while moving the arm into different positions.  Sensation and blood flow in the arm and hand may be assessed, feeling for pulses and determining if there is normal light touch, pain, and vibration sensation in the extremity.

A variety of tests may be performed to discover which of the four muscles of the rotator cuff is injured or damaged.  Each uses muscle contractions to try to find the weak or painful muscle. The Jobe test for the supraspinatus tendon or the Patte test for the infraspinatus and teres minor muscles, or the Gerber test for subscapularis muscle.

One or more of the following diagnostic tests may be ordered as well: 

X-Rays – A rotator cuff tear won’t show up on an x-ray, but the doctor will be able to see bone spurs or other potential causes for pain.

Ultrasound – Assesses the structures of the shoulder as it moves and allows for a quick comparison of the affected shoulder with the healthy one.

MRI – This provides all structures in the shoulder in great detail.

8/17/2018 in Medical Conditions

De Quervain’s Tenosynovitis is an inflammation of tendons and their sheaths on the side of the wrist at the base of the thumb.  It can be brought on by a simple strain injury, but is often the result of repetitive motion injury.  Some causes can be occupational in nature, but also the result of video gaming, lifting young children into car seats, lifting heavy grocery bags by the loops or lifting gardening pots up into place.  De Quervain’s Tenosynovitis can also be caused by a direct blow to the wrist or tendon. 

Risk factors include the following:

  • Age – those between the ages of 30-50 have a higher risk
  • Sex – the condition is more common in women
  • Pregnancy (typically appears 4-6 weeks after delivery)
  • Jobs or hobbies that involve repetitive hand and wrist motions

De Quervain’s tenosynovitis symptoms include a feeling of sharp or dull pain, swelling, and tenderness at the side of the wrist beneath the base of the thumb.  It is typically diagnosed based on typical appearance, location of pain and tenderness.  It can also be diagnosed if pain is experienced when the Finkelstein maneuver is performed.  To do this, bend the thumb down across the palm of the hand and then cover the thumb with the fingers.  Next, bend the wrist toward the little finger.   Lab tests or diagnostic imaging is not required.

Treatment is geared at relieving symptoms such as a splint to stop moving the thumb and wrist, Tylenol or other anti-inflammatory medications, cortisone-type of steroid injection into the tendon compartment.  If these options are not provided relief, surgery to open the tunnel and make more room for the tendons may be considered. 

The results of a recent study suggest in a proportion of participants De Quervain’s tenosynovitis could be secondary to underlying wrist pathology due to previous trauma.  So, if the claimant isn’t reporting a  history of repetitive strain, then the treating physician could be asked to conduct a more thorough assessment to establish if there is any underlying pathology. 

In conclusion, De Quervain’s Tenosynovitis is a temporary condition that generally responds well to treatment.  However, if the condition isn’t treated, it can permanently limit range of motion or cause the tendon sheath to burst.

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