MWCC NO. 97-13377-G-2891

GLENN A. BRUCE                                                                                                                               CLAIMANT

vs.

MEMPHIS STONE AND GRAVEL                                                                                                   EMPLOYER
AND
ROYAL INSURANCE COMPANY OF AMERICA                                                                              CARRIER

REPRESENTING CLAIMANT:
Robert R. Morris, III, Esquire, Batesville, MS

REPRESENTING EMPLOYER/CARRIER:
Marjorie T. O'Donnell, Esquire, Oxford, MS
 

This matter was heard by the Commission on June 26, 2000 pursuant to the Employer's and Carrier's Petition for Review. The Employer and Carrier challenge an Order of Administrative Judge dated March 24, 2000 which found the Claimant had not yet reached maximum medical improvement and was entitled to continuing temporary disability and medical benefits accordingly.
 

It is admitted that Mr. Bruce was involved in an accident on September 17, 1997 while driving a front end loader and injured his right upper extremity. The pain was primarily located in his right wrist, forearm and shoulder. Mr. Bruce continued working that day but went to the emergency room that evening for treatment. From there he was referred to Dr. Stone who, according to Mr. Bruce, advised him to remain off work for one week and see Dr. Ernest Lowe, Jr.

The records from Dr. Lowe reveal that Mr. Bruce was first seen on September 23, 1997 for complaint of right arm pain. Dr. Lowe noted particularly swollen fingers. He prescribed certain medication and therapy. His notes reflect that Mr. Bruce called on September 26 requesting additional pain medication but none was prescribed. Mr. Bruce returned to the clinic on September 29 having completed one round of physical therapy. Dr. Lowe noted that Mr. Bruce was pleased with therapy and it was continued.

On October 1, 1997 Dr. Lowe talked with Mr. Bruce's therapist who felt his complaint's of pain were inconsistent. On October 21, 1997 Dr. Lowe wrote a letter to Royal Insurance stating that he felt Mr. Bruce's complaints of pain had become exaggerated and inconsistent. Dr. Lowe stated there would be no permanent disability.

Mr. Bruce also sought treatment from Dr. A. H. Manugian with the Memphis Orthopedic Group. He saw Dr. Manugian on October 1, 1997 for complaint of right shoulder and hand pain with numbness in the fingers. Dr. Manugian's initial impression after examination was that of right forearm contusion, right rotator cuff strain, and possibly atypical median nerve compression syndrome. Mr. Bruce was given a removable wrist splint and advised to continue with physical therapy and return in one week.

On October 8, 1997 Mr. Bruce returned as scheduled with essentially unchanged complaints. Dr. Manugian noted "multiple inconsistencies on his evaluation" and suggested further testing-and more physical therapy. Each time Dr. Manugian released Mr. Bruce to work with restrictions of 5 pounds continuous lifting, 10 pounds intermittent lifting and no climbing or pushing/pulling above the shoulder.

On October 15, 1997 Dr. Manugian saw Mr. Bruce and confirmed the existence of mild carpal tunnel syndrome by EMG testing, although Dr. Manugian did not feet this "mildly positive EMG" fit with the clinical picture. By October 28 Mr. Bruce was still not admitting to any improvement. Dr. Manugian observed "multiple inconsistencies" once again and noted that Mr.
Bruce had good range of motion in his right shoulder when he was distracted, and full range of motion in his right elbow. For the carpal tunnel problem, Dr. Manugian fitted Mr. Bruce with a cast for one week in order to immobilize the hand and wrist.

The cast was removed on November 4, 1997. At this time Mr. Bruce still reported considerable pain, even in the cast. More than ever, Dr. Manugian observed a number of clinical inconsistencies in Mr. Bruce's examination with the patient's complaints way out of proportion to the findings on examination. Dr. Manugian felt that Mr. Bruce was at this time ready to return to work at full duty and had reached his maximum medical improvement. Dr. Manugian did not feel Mr. Bruce had any permanent impairments or restrictions.

Mr. Bruce returned to work full duty but claims he was unable to continue operating the loader as before. He was put on light duty running errands. He claims his right shoulder, forearm and wrist continued to pain him, and he also claims that his left wrist started to hurt. He returned to the local emergency room on November 12, 1997 and was thereafter referred to Dr. Phillip E. Wright, II, an orthopedic surgeon. Dr. Wright saw Mr. Bruce on November 25, 1997. He did not find anything significant in his examination of Mr. Bruce. Dr. Wright diagnosed a previous right forearm contusion, right arm pain, possible intersection syndrome at the extensor pollis brevis and the abductor pollicis longus, right median nerve compression and rotator cuff tendonitis. He noted that Mr. Bruce "has had a rather full course of treatment" and that Mr. Bruce was not receptive to repeating any of these regimens. For this reason, Dr. Wright suggested that Mr. Bruce may benefit from a unified approach to his problem such as can be obtained through a pain clinic.

Dr. Wright did not see Mr. Bruce again until June 23, 1998, at which time Mr. Bruce was complaining of bilateral forearm pain, right worse than left. In the interim, Mr. Bruce had gone to work at a place called Choctaw as a diesel mechanic, having been laid off in December t998 by Memphis Stone & Gravel. Dr. Wright noted that Mr. Bruce's complaints at this time were more consistent with bilateral carpal tunnel syndrome than in the past. He discussed some treatment options with Mr. Bruce, including surgery, but Dr. Wright noted that Mr. Bruce was rather indecisive and so he was to return as needed.

Mr. Bruce did in fact return to see Dr. Wright on September 4, 1998 complaining of severe wrist pain, bilaterally, that radiated up each arm toward the elbow. Mr. Bruce reported a noticeable worsening of his pain about one month prior. Dr. Wright noted normal function of the shoulder and elbow. He also noted some improvement with regard to the median nerve, or carpal tunnel, problem despite Mr. Bruce's continuing complaints of pain and discomfort.

This was the last time Dr. Wright saw Mr. Bruce, and his diagnoses remained the same as when he first saw Mr. Bruce on November 25, 1997. Insofar as causation is concerned, Dr. Wright felt all of Mr. Bruce's right upper extremity problems were related to his September 17, 1997 injury. Dr. Wright did not, however, have an opinion as to what caused Mr. Bruce to develop carpal-tunnel syndrome on the left other than to say that the injury on September 17, 1997 definitely did not contribute to or cause this problem. At the time of his last visit, Dr. Wright did not feel that Mr. Bruce had yet reached maximum medical improvement. He recommended Mr. Bruce continue wearing his braces and continue treatment in a pain clinic setting if nothing could be done surgically to treat his problems. Dr. Wright did not have any objection to Mr. Bruce continuing his work as a diesel mechanic at Choctaw.

Dr. Moacir Schnapp treated Mr. Bruce at the Mays & Schnapp Pain Clinic beginning January 21, 1998 when Mr. Bruce presented with a complaint of right arm pain. Dr. Schnapp's initial examination did not reveal anything particularly significant and his impression was that of right upper extremity pain, possibly neuropathic or mechanical, possible carpal tunnel syndrome, possible cervical radiculopathy, and depression. Dr. Schnapp suggested a cervical MRI and bone scan to rule out radiculopathy and medication for the pain and depression.

On January 30, 1998 Mr. Bruce returned with a primary complaint of right arm pain. The MRI test and bone scan performed previously were reported as normal, and Mr. Bruce admitted to very little relief from the block he was given. Dr. Schnapp decided to try a repeat block for the arm pain, and to continue treating Mr. Bruce for depression with medication.

Mr. Bruce returned to Dr. Schnapp on March 5 and March 26, 1998, essentially unchanged. EMG and nerve conduction studies were carried out to determine if Mr. Bruce was suffering from carpal tunnel syndrome. These studies confirmed for Dr. Schnapp that Mr. Bruce had carpal tunnel syndrome, bilaterally, and that this was the primary, if not sole, cause of his upper extremity pain. Dr. Schnapp recommended a course of conservative treatment which was never completed by Mr. Bruce.

Insofar as causation is concerned, Dr. Schnapp could not determine whether Mr. Bruce's carpal tunnel syndrome was caused by or contributed to by his employment with Memphis Stone and Gravel. Regarding Mr. Bruce's ability to work, Dr. Schnapp never recommended that he remain off work other than from January 30 to February 6, 1998, and for two weeks beginning February 20, 1998.
 

The chief question here is whether and to what extent Mr. Bruce remains disabled as the result of the September 17, 1997 injury to his right arm.² Important in this determination is the concept of maximum medical improvement. Maximum medical improvement is the point in time when a person has reached the maximum benefit from medical treatment; or, when "the employee is cured or as far restored as the permanent character of his injuries will permit. " Dorris v. Miss. Regional Housing Authority, 695 So. 2d 567 (Miss. 1997), quoting Triangle Distributors v. Russell, 268 So. 2d 911, 912 (Miss. 1972). The point of maximum medical improvement also marks the end of any temporary disability period and focuses our attention on whether any permanent disability benefit is due.

Whether a person has reached maximum medical improvement is a question of fact to be decided on the basis of all the relevant evidence. McGowan v. Orleans Furniture, Inc., 586 So. 2d 163, 168 (Miss. 1991). "The fact that some treatment is necessary, such as physical therapy or drugs, does not necessarily rule out a finding that the condition has become stabilized . . . " Id. Moreover, "[t]he persistence of pain may not of itself prevent a finding that the healing period is over. even if the intensity of the pain fluctuates from time to time, provided again that the underlying condition is stable." Id.; see also John Bryant v. Winston R. Bailey and National American Insurance Co., 94-04200-F-3283 (MWCC May 2, 1997).

In this case, Mr. Bruce was seen early on by two orthopaedic surgeons, Dr. Lowe and Dr. Manugian, for complaint of right arm pain. Both felt that his complaints of right arm pain were seriously exaggerated. Dr. Lowe last saw the Claimant on September 29, 1997 and in a letter to Royal Insurance Company on October 21, 1997 Dr. Lowe deemed Mr. Bruce to be without any permanent disability. Dr. Manugian treated Mr. Bruce from October 1, 1997 through November 4, 1997. He felt Mr. Bruce had clearly reached maximum medical improvement by November 4, 1997 and was without permanent impairment or restriction.

True enough, Mr. Bruce sought other medical attention for continuing complaints of right arm pain, although this treatment was sporadic. Mr. Bruce's right arm condition remained essentially unchanged throughout this additional period of treatment, or so he reported, and this treatment did not seem to produce anything significant in the way of improvement. Dr. Wright saw the Claimant only three times and he noted that Mr. Bruce had previously undergone a "rather full course of treatment. " The only alternative Dr. Wright had to offer was treatment in a pain clinic setting which Mr. Bruce underwent, albeit briefly. Dr. Schnapp, who treated Mr. Bruce at the pain clinic, ultimately determined that the chief component of Mr. Bruce's pain complaints was carpal tunnel syndrome of unknown etiology.

We conclude, on the basis of all the relevant evidence, that Mr. Bruce reached a point of maximum medical improvement in regard to his September 17,1997 right arm injury at least by November 4, 1997 as established by Dr. Manugian. The fact that he continued to seek treatment thereafter on an intermittent basis for continued complaints of pain does not change our conclusion that the underlying condition resulting from his September 17, 1997 injury was well stabilized and as improved as it was likely to get by this time.

We find further that Mr. Bruce's September 17, 1997 injury did not result in any permanent disability. Not only did his treating physicians fall to assign any permanent impairment or restrictions, he eventually returned to work as a diesel mechanic working 40 to 50 hours per week and fully earning more money than he made prior to his injury. By all accounts he performs this work admirably and without any apparent difficulty. Under any view of the Law, therefore, he has failed to prove that he suffers from any permanent disability.
 

The Order of Administrative Judge dated March 24, 2000 is reversed and vacated. The Employer and Carrier are hereby directed to pay the Claimant temporary disability benefits at the appropriate rate for any period of time between September 17, 1997 and November 4, 1997 in which Mr. Bruce was unable, because of the injury to his right arm, to earn his full pre-injury pay, with credit for any and all workers' compensation benefits previously paid. The Employer and Carrier shall also provide and pay for all medical treatment reasonably and necessarily related to his right arm injury. Mr. Bruce's claim for permanent disability benefits is hereby denied and dismissed.

SO ORDERED this the 31st day of August, 2000.

MISSISSIPPI WORKERS' COMPENSATION COMMISSION
Barney Schoby
Beverly Bolton

ATTEST:
Joann McDonald, Secretary
___________________________
 

MWCC NO. 97 13377-G-2891

GLENN A. BRUCE                                                                                                                               CLAIMANT

vs.

MEMPHIS STONE AND GRAVEL                                                                                                   EMPLOYER
AND
ROYAL INSURANCE COMPANY OF AMERICA                                                                              CARRIER

APPEARING FOR CLAIMANT:
Honorable Robert R. Morris, III, Attorney at Law, Batesville, Mississippi

APPEARING FOR DEFENDANTS:
Honorable Marjorie T. O'Donnell, Attorney at Law, Oxford, Mississippi
 

A hearing was held on October 19, 1999, at 2:00 p.m. at the Panola County Courthouse located in Batesville, Mississippi. This cause concerns an admitted injury suffered by the claimant while in the employ of the instant employer.

Prior to going onto the record in this cause, the parties entered into the following stipulations:

1. The average weekly wage of the claimant was determined to be $480.29;

2. It was further stipulated that $812.01 had been paid to the claimant in indemnity benefits for two periods of time, namely, 9-23-97 through 9-29-97 and a subsequent period of 2-6-98 through 2-20-98.

The existence, nature, and extent of disability attributable to the injury inclusive of the date of maximum medical improvement, if attained, and if no, claimant's entitlement to future medical benefits.
 

The claimant testified on the occasion of this hearing that he was born on November 24, 1966. He is a current resident of Marks, Mississippi. Claimant testified to a date of injury of September 17, 1997 and noted that he worked primarily as a front-end loader. He has been married for the last five years and has three children. Claimant completed the eleventh grade at Sardis High School, but did not attain a GED and testifies to no further specialized training, vocational or otherwise. The claimant related to the Commission all particulars of his accident, which is admitted in nature, and all the treatment he has received by various physicians. Claimant testified that although it has been quite some time since he has seen a doctor, over a year since claimant has seen Dr. Wright, claimant indicates he is not released from Dr. Wright The claimant testified to a present condition wherein both his hands ache and hurt and he "walks the floor at night". Both hands are numb in the mornings when he awakens, All symptomology he reports is worse on his right side. It is noted that the claimant was laid off by the instant employer in December of 1997 due to a lack of work and he received unemployment benefits for a certain period of time subsequent thereto. The claimant currently works at a greater rate of pay at Choctaw Industries where he works as a diesel mechanic obtaining 40 to 50 hours a week at $10.00 plus per hour. He also "sometimes" runs a dozer for his brother-in-law for which he is paid $8.00 per hour in cash, but he only did this for a month or so. Therefore, he does not suffer any loss of wage-earning capacity as a result of this injury, but rather seeks future medical attention. The claimant testified to a date of hire of March 4, 1996, and his main job allowed him to achieve up to $8.85 per hour prior to his layoff.

The claimant called his wife, Linda Bruce, who has been his wife for the past five years. Her testimony was cumulative and corroborative in nature to that of the claimant.

The defense called Raymond William Owens, Jr., who is the Director of Human Resources and Safety for this employer and a consultant for all personnel decisions. He testified that the location of the Grenada "pit" where the claimant worked was completely shut down and dismantled by February of 1998 and that the claimant was never fired by the company. As to the layoff which occurred in December of 1997, he testified this was a usual and customary layoff. He also reported that the claimant was dissatisfied with Dr. Lowe and the claimant had told him so. Mr. Owens then sent the claimant to Dr. Manugian in Memphis for further treatment.

Dr. Phillip E. Wright, II, an Orthopedic Surgeon, testified by deposition in this cause. He noted that he first saw Mr. Bruce on November 25, 1997, and he was seen on that day for a second opinion regarding an injury that he had sustained while on the job. Mr. Bruce indicated that while working as a heavy equipment operator he was injured on September 17, 1997. He noted that while working a front-end loader the soil under the loader gave way and the claimant bounced around the cab of the loader and struck his right shoulder and the back of his right forearm against the cab. Claimant had pain and swelling and bruising of the forearm. He reiterated for this physician his treatment by Dr. Ball in the emergency room and subsequently by Dr. Stone and Dr. Lowe, an Orthopedic Surgeon of Oxford, Mississippi. Claimant had a diagnosis of right forearm contusion, right rotator cuff strain, atypical medial nerve compression. There was also some evidence of compression of the nerve at his wrist and his carpal tunnel on the right side. Prior thereto, he had received a number of pain medications and other medications, some injections, and been immobilized in a wrist splint and a cast on his forearm. He noted that he had very little relief from these treatments and had also had a course of physical therapy on two separate occasions. Dr. Wright noted that on that date he was hurting mainly in the back of his forearm, side opposite his palm, mainly down toward the wrist, just above the wrist where some tendons cross in that area. He also had some shoulder pain. Claimant did not feel he had relief from the treatments that he received up until this point. He indicated he had not been able to return to work because of these problems. Dr. Wright performed a physical examination. After his physical exam and review of the tests and history that he took, he made an initial diagnosis that Mr. Bruce had a contusion to his right forearm and right shoulder, had upper extremity pain and "probably" a tendonitis and inflammation of the covering of the tendon and the muscle to help move his thumb up and toward the back of his hand. He felt he probably had tendonitis in the region of the right shoulder and his rotator cuff tendon as well. Dr. Wright's suggestion at that time was that he be followed in a pain clinic setting to try to got some of the painful areas under control. It was his impression that he was continuing to be followed by Dr. Ball and that he was to return for follow-ups with Dr. Ball. It was also his feeling at the time that he did not require any specific and invasive treatment in the way of injections or surgical procedures. He next saw him on June 23, 1998. Mr. Bruce informed him at that time that he had been followed in a pain clinic by Dr. Schnapp and his last visit had been in May, 1998. He did not have records at that time from Dr. Schnapp. While in Dr. Schnapp's clinic he had also been evaluated by Dr. Martinez, and electrical studies had been done by Dr. Martinez on March 16, 1998. They were able to get the results and they showed evidence of pressure on the median nerve and the carpal tunnel on both the left and right side. He performed another physical examination. Although he made no additional diagnosis at the time he-reflected that Mr. Bruce's complaints seemed to be more consistent with pressure on the median nerve and his carpal tunnel in his wrists on both sides than they had been when he had seen him in November of 1997. It seemed he had a changing picture, having pain on the back of the wrists and his shoulders at one time, and then sensations of pain and tingling and numbness in his hands and fingers at other times. Claimant returned to see him on September 4, 1998, approximately two and one-half months later. He indicated that the pain had increased in both sides and had started worsening about a month prior to that visit. Dr. Wright indicated that he felt that the pain was discomfort on the surface of his forearms or the outside of his forearms. He had been doing mechanic work but said that at times the pain was so bad he could not work and he had not been working on a regular basis. Claimant had been taking Motrin (or Tylenol) for his discomfort but had not been wearing his splints. Another physical examination was had. Upon examination his diagnoses were essentially the same without any additional findings to those that had been mentioned previously. Dr. Wright did feel at that time that he had improved regarding his shoulder complaints and fingers and also some improvement as far as the physical examination is concerned regarding the median nerve and the carpal tunnel problem. However, he continued to have discomfort in the tendon area on the back of his wrists. He has not seen the claimant since that visit. Dr. Wright noted that he had an opinion to a reasonable degree of medical probability as to the cause of each of the diagnoses as delineated and he indicated based on the injury that Mr. Bruce had told him by way of history, the conditions were caused by his on-the-job injury that he described as having occurred on September 17, 1997. This injury would encompass all five of the diagnoses made. However, special reference is taken to the fifth diagnosis regarding Mr. Bruce's left upper extremity and he noted that the electrical test that had been done by Dr. Martinez in March of 1998 would be consistent with carpal tunnel syndrome on that side as well, but he did not have a reasonable medical probability as to the causal connection of the left sided condition. This doctor noted that he could not opine as to any permanent impairment as a result of the injuries he sustained and did not examine him to determine any such permanent medical impairment. However, at the time of his deposition, he did not feel that the claimant had reached maximum medical improvement, so an estimation of his permanent physical impairment has not been made. He recommended that as far as treatment options were concerned, Mr. Bruce should continue wearing his braces and if he has pain that cannot be clearly described as anything to be treated surgically, he should be followed up in a pain clinic setting. There was some indication that the condition that Mr. Bruce was complaining of would be benefited by surgery, particularly in the realm of the median nerve compression or carpal tunnel syndrome. If it persists and fails to respond and is clear cut, same could benefit from surgery. However, the shoulder problem would not likely require surgery based on his apparent gradual improvement and the tendonitis problem in his wrists would not likely require surgery either. This doctor opined that it would be fair to say that the accident that he incurred at work in September of 1997 would not be the cause of the left extremity pain or carpal tunnel syndrome on that side. He noted that he did not have any history first hand from Mr. Bruce or from any review of the records of the physicians who treated him that he had had any injury to the left side in September of 1997. In fact, he reported that he bumped his right shoulder and right forearm and that was all that was reported to have occurred in that accident. He also noted by clarification that as he was seeing the claimant approximately three months later after his injury, his impression regarding an aggravation or possible worsening of median nerve problem or even such an injury causing a median nerve problem was based on the history that claimant gave of having had swelling and bruising about his forearm and hand and this was confirmed in one of the notes of one of the treating doctors who did see him at the time of the injury, so that was the reason that he ascribed possible aggravation of a median nerve problem to that as it would be consistent with having had swelling and bruising around his forearm and hand. He further noted that as far as the shoulder injury was concerned and the limitation of motion which Mr. Bruce expressed upon examination, that limitation of motion would be consistent with the injury which he described in the history that he took. It would appear that he had a loss of motion or limitation in the left and right shoulder. His final remark was to a reasonable degree of medical probability noting he did not feel that Mr. Bruce had reached a state of maximum medical improvement.

Dr. Moacir Schnapp testified by deposition in this cause. Dr. Schnapp is a Neurologist who has a sub-specialty in pain management. He noted that Mr. Bruce came to him by referral from Dr. David Ball and he first saw him on January 21, 1998. He noted by history that the gentlemen apparently "got hurt" when he bumped his forearm at work around September of 1997. Claimant had immediate swelling around that area, but a local x-ray did not show anything major. Claimant continued to have pain in that area which he described as radiating into his right hand and shoulder. A physical examination was had. Based on his physical exam he considered the history taken to be consistent with the examination and made the following diagnoses: (1) Right upper extremity pain, rule out neuropathic versus mechanical, post-traumatic; (2) Left upper extremity numbness, rule out carpal tunnel; (3) Rule out cervical radiculopathy; (4) Depression. He suggested an MRI of the cervical spine and a bone scan, and they started him on antidepressants and performed nerve blocks on that day. He next saw him on January 30, 1998 and his condition was essentially unchanged. At that time they saw no signs of a ruptured disc or a nerve compression on the MRI. The bone scan was negative and they proceeded with a repeat block. The only treatment was on the right side and no treatment at that time was to the left arm. However, Mr. Bruce continued to complain of pain in his left arm. He next saw him on March 5, 1998, essentially unchanged. Another physical examination was done. At that time his diagnosis was right upper extremity pain, neuropathic, rule out carpal tunnel. Dr. Schnapp did not want to, however, state that he had carpal tunnel without confirming it. They repeated the EMG and nerve conduction studies. The EMG was done on 3-16-98 and from that he was able to determine an abnormal study with evidence of a moderate demyelinated compression neuropathy involving the median nerve at the level of the wrists bilaterally, i.e. bilateral carpal tunnel syndrome. Also, there is no conclusive electrophysiologic evidence of a right cervical radiculopathy or right brachialplexopathy. There was also no evidence of sensory neuro injury to the superficial sensory brach of the right radial nerve. The EMG did affect his diagnosis in that it confirmed the suspicion that carpal tunnel is a significant component, if not the major component of this man's complaints. Dr. Schnapp saw him again on March 26th of 1998 and he was still hurting and still had bilateral complaints. He recommended intensive rehabilitation and conservative treatment management, but if this was not the case another opinion from a surgeon regarding possible carpal tunnel releases needed to be obtained. Claimant apparently did not have the recommended intensive rehabilitative therapy, noting that it was not approved by the insurance company. He also indicated in response to the question regarding the claimant's employment as a front-and loader (which involved steering and manipulating the levers and was a five to six day a week job, usually 9 or 10 hours a day,) and if such was the case he would say the continuous repetitive motion could be a possible cause of the claimant's bilateral carpal syndrome condition as the continuous repetitive motion would be a significant component. However, he could not state within a reasonable degree of medical certainty what was the actual cause of his carpal tunnel condition. He did opine that carpal tunnel is often bilateral. It may start on one side, but very often involves both sides and again could be related to systemic changes in the body that could account for that, but it did not surprise him that his symptoms were bilateral in nature. He was asked his opinion to a reasonable degree of medical probability as to what type of treatment, if any, Mr. Bruce needs at this time, and he indicated that although he did not have the benefit of Dr. Wright's last consultation, assuming that Dr. Wright finds that his carpal tunnel is treatable with surgery, chances are good that surgery would be needed as the next step. He also indicated it was his opinion that claimant had a genuine complaint and believed his pain was credible. Dr. Schnapp did not see him as either a malingerer or a histrionic personality. He also indicated that he referred Mr. Bruce for treatment by Dr. Wright concerning the carpal tunnel. He noted that Dr. Wright had seen him in the past and he wanted Dr. Wright to re-evaluate him and compare with his previous examination. Dr. Schnapp certainly felt that this was a reasonable and necessary referral to make. He noted that upon first presentation he did indeed complain of both right and left upper extremity pain, indicating right upper extremity pain for the past four months and pain to the left arm noting that it would "go to sleep" as well as a burning, tingling sensation on the right side. Dr. Schnapp testified that he was aware the claimant was working and the medical question here is if there is a significant component of carpal tunnel bilateral and if this is made worse by the level of activity he does, the chances are that he will suffer further nerve damage in the future. The fact that he works reflects what the majority of people with carpal tunnel do, they continue to work and continue their activities at least until the pain becomes excruciating. He also indicated once again that he would defer to the surgeon, Dr. Phillip Wright as to the question of surgery for this claimant. He testified that although his notes did not necessarily reflect complaints related to the left side of the claimant, his major complaint was right-sided and therefore, it was quite possible that Mr. Bruce complained to him of problems with his left arm and they did not always get relayed into the notes he dictated at a later time.

Dr. Arsen H. Manugian testified by deposition in this cause. Dr. Manugian is an Orthopedic Surgeon. He first saw claimant on October 1st, 1997, with a chief complaint of pain in the right shoulder, arm, hand, with intermittent throbbing and numbness in the ring and long fingers. He took a history from him on that date with all the pertinent details and performed a physical examination on the claimant. His impression on that day was that claimant had a forearm contusion, a bruising of his forearm, a strain of his rotator cuff, which are the muscles around the shoulder, vague right hand symptoms, and a necessity for ruling out the possibility of atypical median nerve compression syndrome, which is what carpal tunnel is. His recommendations were splints for his wrists and all findings were discussed with him. Claimant was to continue his physical therapy and medication. He was allowed to go back to some modified work responsibilities. Claimant did not on that occasion complain of left upper extremity pain at all. He noted that the claimant was a difficult historian and had multiple inconsistencies on his evaluation. Claimant was given an injection in his shoulder and an EMG was ordered. He continued to treat him throughout October of 1997. His EMG upon achievement showed that he had mild carpal tunnel symptoms and the findings were discussed with him. Dr. Manugian noted that he documented these replete difficulties with the history, inconsistencies and difficulty with communicating with the patient. By November of 1997 upon examination this doctor opined that the claimant had negative carpal tunnel symptoms. He last examined him on November 4, 1997 and had an opinion to a reasonable degree of medical probability that the claimant had reached maximum medical improvement on that date and he released him to return to full duty. He was also asked his opinion to the same applicable standard as to whether or not the claimant had any permanent restrictions or impairments and he noted he did not think he had any. Basically, this physician could not find an underlying pathological process that he could explain as an orthopedist that would be consistent with his physical complaints. By way of noting the mild carpal tunnel he felt was evinced on the EMG, he testified that he did not consider Mr. Bruce as a candidate for carpal tunnel releases in that he did not feel that the positive EMG findings "really fit" the clinical picture.

Dr. Ernest B. Lowe, Jr., testified by Medical Records Affidavit in this cause. Apparently first presentation was on 9-23-97 and it was noted he came in for evaluation of his right arm. "Approximately a week ago he bumped it with a loader and sustained an injury to his right arm." He saw him again on 9-29-97 and then for the final time on 10-1-97. In a letter dated October 21, 1997 he noted that he felt claimant's pains that he described were exaggerated and were not consistent and felt at this point that there would be no permanent partial medical impairment.

Dr. David Ball of the Batesville Clinic testified by Medical Records Affidavit in this cause. Dr. Ball apparently treated him for median nerve compression syndrome. These records appear to be confined to right-sided complaints and also indicate his referral to Dr. Wright as alluded to in other portions of this Opinion.

Employer and Carrier Exhibit 8 is the Medical Records Affidavit of the South Panola Community Hospital and indicate visits by the claimant commencing in 1988 and concluding in June of 1998. They cover complaints of right arm pain and treatment relative to the work injury and other incidental records from other maladies suffered by the claimant.

Claimant Exhibit 7 is the Medical Records Affidavit relative to the Health South Rehabilitation, formerly the Rehab Group of Batesville, which reflects treatment in the realm of therapy for the claimant. Same indicates that he was running heavy equipment when the loader "fell off" and hit the right shoulder and wrist. He complained of numbness in the long ring and middle fingers and grinding in the right shoulder. Claimant was asked to complete the shoulder and forearm program, right side. Apparently Dr. Manugian referred him to the rehab group for this treatment which commenced in October of 1997. In a letter dated October 8, 1997, the Rehab Group wrote to Dr. Manugian and noted that his treatments consisted of right upper extremity range of motion and strengthening exercises and revealed that at his last visit on 10-6-97 he voiced no improvement and complained of right shoulder and forearm pain. The conclusion of this letter indicates that overall no improvement has been noted with the rehab and Mr. Bruce did provide good cooperation and effort with rehab. Later a referral is reflected in the affidavit from Dr. Ball to the Rehab Group asking that they evaluate and treat him for his nerve compression syndrome and this entry was dated 12-1-97. Apparently they continued to treat him for this malady in the month of December. The Rehab Group wrote to Dr. Ball on December 11, 1997. Once again he had attended the rehab with good compliance but once again Mr. Bruce reported no improvement thus far with rehab and continued with complaints of pain, swelling and numbness. The pain was with movement and use of his right upper extremity. In conclusion, the physical therapist wrote that therapy has not helped to decrease Mr. Bruce's pain, it has only helped him to maintain his motion and try to decrease his pain. Upon a discharge date of 12-17-97, he was given a prognosis of "poor".

Employer and Carrier Exhibit 8 is an article from the Panolian, the Batesville, Mississippi paper dated Friday, June 19, 1998, and includes an article written by Samantha Toliver to her stepfather, Mr. Glenn Bruce, and states that he is a Father of the Year nominee. Apparently significant herein is the statement written by Mr. Bruce's stepdaughter, which states "he works two jobs to support his family to their fullest needs".

Employer and Carrier Exhibit 9 is indicative of the claimant's schedule of work during the calendar year 1997 and shows the dates he did and did not work.

Employer and Carrier Exhibit 10 is an Employee Notice of various infractions by the claimant while in the employ of the instant employer. On 11-7-97 apparently the violation of the rule was that he left without informing his supervisor and was placed on probation. On 11-14-97 he was given a final warning when he once again left without performing or satisfying the proper procedure to go to a doctor's appointment. By 11-17-97 it was noted that he did not show up or call in and had not done so since three days prior thereto. "Also the employee has not given any excuse for being absent." However, the employee did phone in on 11-18-97 and said he was not coming as he was going to the doctor, which was an acceptable excuse for being off on that date.

Employer and Carrier Exhibit 12 is a two page document indicating a history of problems with Glenn Bruce and has a reflected date of 11-25-97. These problems appear to center around the claimant's non-conformance with policies in place as regards missed days of work and other personnel matters.
 

Upon evaluation of all testimony, lay and medical, and based upon a preponderance of the evidence supported by applicable law, I hereby render the following findings of fact:

The clinical , medical picture for this claimant is murky at best and must be developed further to insure the injured worker has a complete and successful resolution from this admitted work-related injury. Most significant is the medical testimony of Dr. Philip E. Wright, II, who opined that the claimant has not achieved maximum medical benefit. Development of the claimant's prognosis and a course of further treatment is clearly indicated and should be afforded to the claimant. Until such medical criterion and treatment has been achieved, this claimant will not be ripe to determine what permanent disability, if any, in an industrial sense and/or lack of wage-earning capacity the claimant might have suffered as a result of this work-related injury.
 

IT IS, THEREFORE, ORDERED AND ADJUDGED that the employer, Memphis Stone and Gravel, and carrier, Royal Insurance Company of America, provide medical services and supplies to the claimant in accordance with Mississippi Code Annotated, § 71-3-15 (1972) until such time as claimant is deemed by reputable and unequivocal medical evidence to be at maximum medical improvement. Further, claimant is to be paid indemnity benefits if applicable during this period of recovery with proper credit to be applied for any and all monies, wages or benefits paid during the affected time periods as outlined by Mississippi Code Annotated, Section 71-3-17(c) (1972).

SO ORDERED this the 24th day of March, 2000.

VIRGINIA WILSON MOUNGER
ADMINISTRATIVE JUDGE

ATTEST:
Brenda H. Goolsby, Secretary
___________________________

1. Chairman Smith recused himself.

2. The evidence clearly fails to establish any connection between Mr. Bruce's left carpal tunnel syndrome and his September 17, 1997 injury so we deal only with the right upper extremity injury. The Employer and Carrier are not responsible for any medical treatment or disability related to the left upper extremity.