Occupational Orthopedic Medical Group Addresses Causation

Saturday, July 14, 2007 | 2

By Dr. Gilbert Jody

It has been two years since the passage of SB 899 and many workers' compensation medical providers are still not proficient in dealing with the issue of apportionment of treatment to causation. Prior to 2004, apportionment in Workers' Compensation was only directed towards permanent disability issues.

The new legislation allows for treatment of the acute injury to be determined by causation. Prior to 2004, if a worker claimed a work-related injury and it was an accepted injury, all treatment was covered under the existing workers' compensation rules and regulations. Treatment was not affected by pre-existing conditions (disease or illness). In effect when an employee was hired by a company, the company bought his medical history.

The following are two good examples demonstrating the new issue of causation affecting treatment.

Example 1: 30-year-old male working for a telephone company climbs a telephone pole and feels a sudden pain in the knee and develops slight swelling. He is seen at the local industrial clinic and is determined to have a possible internal derangement of the knee. He undergoes a MRI which shows an old ACL tear along with a possible meniscal tear. Patient is referred to an orthopedic surgeon who determines he has an unstable knee as well as a meniscal tear and recommends arthroscopic menisectomy and ACL reconstruction.

Prior to SB 899, although the mechanism of the injury could not have caused the ACL tear, the employer was responsible for the surgery.

Under the new laws, it would be clearly shown that the mechanism of injury mainly climbing the pole could not have resulted in ACL tear. The physical findings show that lacking acute significant knee swelling and MRI changes showing an old ACL tear, demonstrates that the ACL injury was pre-existing to this industrial exposure. Therefore under the new laws which apportions treatment to causation, the patient could undergo an arthroscopic menisectomy to correct the meniscal tear, but the employer would not be responsible for the ACL tear. The reconstructive surgery for the old ACL tear would be performed on a private basis resulting in tremendous savings on the treatment and disability side.

Example 2: 50-year-old male working for a company for three months sustains an acute low back injury from lifting. He is seen at an Occupational Medicine Clinic. Primary findings are low back pain and stiffness. Patient has no neurological abnormalities. X-rays show significant DDD at L 4-S 1. He does not improve after two weeks of physical therapy. He undergoes a MRI scan which also confirms significant degenerate disease L 4-S 1 but no acute disc. He is then evaluated by an orthopedic surgeon who under the new law must make it clear that the primary problem DDD L 4-S 1 is pre-existing and pre-dated the employee's hiring date.

Per ACOEM guidelines, the patient could treat conservatively for six weeks with medication and physical therapy to bring him back to pre-injury status.

Under the new laws, the employer could not be held accountable for the possible need for spinal decompression and fusion based on the nature of the injury and pre-existing factors.

Both cases are classical examples of how the new legislation allowing for apportionment of treatment to causation can save thousands of dollars and limit the liability of the employer to only treating the symptoms that were directly a result of the work injury. These issues must be clearly understood and addressed by orthopedists who continue to treat musculoskeletal work injuries.

Dr. Gilbert Jody was the primary orthopedic consultant for TRW, Northrop, Aero Space Corp. and Rockwell International from 1979 to 1985. In 1985, Jody founded Occupational Orthopedic Medical Group (OOMG), an orthopedic network dedicated to treating injured workers in Los Angeles, Orange and Inland Empire Counties. As of January 2007, Dr. Jody has developed an independent statewide orthopedic network for treating workers' musculoskeletal injuries. For more information or a listing of physicians and locations, please call Rosario Briones at 213-484-1873.

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