I am recovering from my second spine surgery in the last seven months. At this point, I am completing physical therapy as part of my rehabilitation protocol. As I left the therapist’s office, I was acutely aware I do not bounce back from physical stress the way I used to. This raises one of the most important causation questions a claim professional will ever face: Is the pathology the result of the reported injury, or is it simply the natural consequence of aging?
Diagnostic Imaging Can Reveal More Than the Injury
I say this because modern medical practice frequently relies on advanced diagnostic imaging to better understand the patient’s condition. During the course of this evaluation, any number of ordinary disease of life, pre-existing degenerative findings can be discovered. All too frequently these findings, such as disc bulges, rotator cuff tears, meniscal lesions, and other findings are felt to be a function of the identified event. After all, age matters. A 25-year-old shoulder and a 65-year-old shoulder should not be expected to look the same on enhanced imaging studies.
Claim Creep Starts When Degeneration Is Mistaken for Injury
The problem is many of these findings are fairly common in otherwise healthy working individuals and are not a function of the reported compensable injury. For those claim file professionals working in our ecosystem, one of the more important skills that must be developed is the ability to ascertain the difference between age-related degeneration and an acute injury. With this skill, you can prevent claim creep and support more defensible claims determinations.
Begin with the Mechanism of Injury
The initial first step is to understand the reported mechanism of injury from a pure biomechanical sense. Ask yourself these questions:
- What exactly happened?
- Was there sufficient force present that would be a competent clinical explanation for the claimed condition?
- Does the reported mechanism of injury align with the diagnosis assigned?
Connecting the Mechanism of Injury to the Diagnosis
As an example, the injured worker reports shoulder pain after reaching for an object on the top shelf of the central supply storage cabinet. Did this effort really cause a full thickness rotator cuff tear with retraction of the tendons? The point is simple; a credible diagnosis needs a credible mechanism of injury behind it. When you look at the age demographic of this individual, the findings on plain radiographs documenting degenerative changes, and the physical examination reported what most probably happened is that this individual has an impingement syndrome of the shoulder and the rotator cuff has simply worn down over the years, not in a single moment.
Understanding Symptoms vs Clinical Findings
Please remember that symptoms are different from objective medical findings. Pain is a symptom. An injury requires specific objective medical evidence. With each clinical evaluation the assessment begins with the subjective complaints offered by the injured individual, followed by physical examination findings, which would include strength deficits, neurologic abnormalities, and measurable loss of function. The point to remember is that symptoms that began after the noted work injury do not automatically establish that every finding on diagnostic imaging studies is related to or a function of the identified event. Do not confuse changes on diagnostic imaging studies with the compensable injury sustained. Remember, the MRI study can tell you what is there, it cannot tell you how it got there.
Acute Injuries Leave Clinical Evidence
Read the initial and subsequent evaluations carefully, acute injuries always leave specific clues. In addition to the immediate onset of symptomology, the body will respond to acute injury with swelling, bruising, or other markers of acute injury. If the injury is a function of this event, you should be able to identify a logical progression of symptoms from the date of injury forward. And again, check whether the MRI shows changes on T2 or STIR sequences, the images that pick-up fluid and swelling (markers of acute changes) which confirms a finding of a recent, rather than old injury.
Does the Evidence Support the Claimed Injury?
The more competent, objective, and independently confirmable medical evidence that appears immediately after the event strengthens the argument that the pathology noted is acute. Conversely, the lack of specific objective parameters speaks to the “unrelated comorbidity” nature of the pathology identified.
The Goal Is a Defensible Claim Determination
The question that remains is not whether the pathology exists, but rather if the pathology is a function of the reported mechanism of injury. Ask the injured individual on multiple occasions exactly what happened. When claim professionals focus on the mechanism of injury, the objective clinical findings noted, the correlation of these findings to the compensable event, and establish a true distinction between what is an ordinary disease of life degenerative change and acute trauma. This will enable you to reach a fair, defensible determination of the extent of injury and guide your future decisions. And as always, if you have any questions, ask for assistance.
