Source: http://wcc.dli.mt.gov/L/Lockwood_FFCL.htm
Timestamp: 2019-04-21 06:40:36+00:00

Document:
Summary: The claimant suffered from a preexisting anatomical abnormality of her knee, predisposing her to dislocation of her kneecap. Prior to 2001, she had dislocated her kneecap (patella) on at least one occasion and suffered twisting injuries on other occasions. In June 2001, she suffered a dislocation of her knee at work. Her employer’s insurer accepted liability for the injury. Nine months later she suffered a more serious nonwork- related patellar dislocation while shoveling snow. The insurer denied liability for benefits after that injury.
Held: The claimant reached maximum medical improvement (MMI) prior to her March 2002 injury. The March 2001 injury was a material, permanent aggravation of her preexisting condition. Under section 39-71-407(5), MCA (1999), that subsequent, nonwork- related injury relieved the insurer of further liability for her patellar condition.
Constitutions, Statutes, Regulations, and Rules: Montana Code: section 39-71-407(5), MCA (1999). Where the claimant reached MMI following a work-related patellar dislocation, and thereafter suffered a material, permanent aggravation of her patellar condition in a nonwork-related injury, the insurer for the work-related injury is relieved of further liability under section 39-71-407(5), MCA (1999).
Injury and Accident: Aggravation: Generally. Where the claimant reached MMI following a work-related patellar dislocation, and thereafter suffered a material, permanent aggravation of her patellar condition in a nonwork- related injury, the insurer for the work-related injury is relieved of further liability under section 39-71-407(5), MCA (1999).
Injury and Accident: Subsequent Injury. Where the claimant reached MMI following a work-related patellar dislocation, and thereafter suffered a material, permanent aggravation of her patellar condition in a nonwork- related injury, the insurer for the work-related injury is relieved of further liability under section 39-71-407(5), MCA (1999).
Maximum Medical Improvement (MMI). Where the claimant suffered a work-related dislocated patella; an orthopedic physician testified that the claimant likely reached MMI within six weeks of a patellar dislocation; the claimant returned to work and worked steadily for the next nine months; the claimant by her own admission was experiencing no knee symptoms a week prior to a subsequent injury which occurred nine months later; and by her own admission during the month prior to the subsequent injury her knee “bothered her every now and then,” and only when she stood for a long time; and then the claimant again dislocated her patella in another accident, the Court finds that the claimant had reached MMI prior to the subsequent injury.
Maximum Medical Improvement (MMI). Where the claimant has access to but fails to take advantage of the only treatment prescribed for her injury, she is at MMI.
¶1 The trial in this matter was held in Great Falls, Montana on September 8, 2003. Petitioner, Wendy Lockwood (claimant), was present and represented by Ms. Charla K. Tadlock. Respondent, Liberty Northwest Insurance Corporation (Liberty), was represented by Ms. Carrie L. Garber.
¶2 Exhibits: Exhibits 1 thorough 7 were admitted without objection.
¶3 Witness and Depositions: Claimant was the sole witness at trial. In addition, the parties submitted the depositions of the claimant, Randale Sechrest, M.D., Candi Shalz, Jennifer Swanson, Daniel P. Rausch, M.D., and Donna Kanewischer for the Court’s consideration.
¶4a Whether Liberty Northwest Ins. Corp. is liable for the Petitioner’s knee condition after 3/17/02.
¶4b Whether Petitioner is entitled to payment of past and future medical benefits, temporary total disability benefits, temporary partial disability benefits, and future benefits allowed by the workers’ compensation law.
S The patient states that her knee was injured several years ago and she has reinjured it a time or two. One time she had a dislocated patella which relocated more or loss [sic] spontaneously. Intermittently when she is walking or running and plants weight on that leg and turns, it will collapse and she will fall. Then the knee will fill up with blood or at least develop an effusion and be sore for a number of days. She has not really fallen for several months, but a number of times she felt as if she was on the verge of falling when she planted the knee and then turned on it a bit. It will stay sore for a few days then. She apparently had x-rays a number of years ago out in California which were interpreted as being negative.
¶8 The claimant was referred to Dr. Gregory S. Tierney, an orthopedic surgeon practicing in Great Falls. He saw her on March 7, 1997. (Ex. 3 at 54, 57.) His assessment of her right knee was “a probable right patellofemoral subluxation with continued maltracking.” (Id. at 57.) He recommended “a course of physical therapy to work on patellar tracking and quadriceps strengthening.” (Id.) However, there is no record of any physical therapy following the recommendation.
¶9 In September of 1997, the claimant went to work at the Main Street Convenience Store in Shelby, Montana (see Ex. 1), and continues to be employed there. She works as a cashier.
¶12 Five days later – June 25, 2001 – the claimant underwent an MRI of her right knee. The MRI was read as indicating the “patella is displaced slightly laterally” and a possible tear of the medial meniscus. (Ex. 3 at 7, 28-29.) The claimant was seen by her family physician, Dr. Daniel P. Rausch, and referred back to Dr. Tierney, who had seen she in 1997.
¶13 The claimant was thereafter seen on July 24, 2001, by Dr. Tierney and his physician’s assistant. (Id. at 54.) Dr. Tierney reviewed the MRI and found no evidence of a meniscal tear. He noted, however, that “her patella is somewhat displaced laterally.” (Id.) He diagnosed “[c]hronic patellofemoral maltracking” and prescribed “a formal course of physical therapy to try and help avoid any of these recurrent subluxations in the future.” (Id.) He gave her a prescription for physical therapy.
¶14 At the time of the incident, the claimant’s employer was insured by Liberty. She submitted a claim to Liberty, which accepted liability. Liberty thereafter paid medical bills relating to the claimant’s right knee. The last medical bill paid was for Dr. Tierney’s July 24, 2001 exam.
¶15 Even though Liberty agreed to pay the claimant’s medical expenses for her injury, the claimant never followed through with the physical therapy prescribed by Dr. Tierney. At trial she testified that she did not go to physical therapy because it would have interfered with her job schedule at the convenience store and she needed the money she was earning from her job. Her excuse was not believable. According to her own testimony, her hours of work were 2:00 p.m. to 10:00 p.m. or 3:00 p.m. to 11:00 p.m. There was ample time during the morning hours for her to have obtained physical therapy.
¶16 Between July 24, 2001 and March 17, 2002, the claimant did not seek medical care for her knee.
H.I.: This is a 29-year-old white female patient who I am familiar with whom approximately a year ago she had a similar incident which she was able to self reduce her kneecap. [sic] She states that she has not been having any problems for the most part until this morning when she was apparently shoveling snow, twisted on her knee and ended up going down on the ground. Apparently the ambulance had to come to get her and bring her in. Her patellar in fact was on the lateral aspect of her knee when she got here. She was in a sitting up position with the knee flexed. She was in a fair amount of pain. Good pulses.
. . . We saw Wendy [claimant] for a similar problem back in July 2001 at which time we recommended physical therapy. She has been actually referred to physical therapy on several different occasions by different physicians and she has not yet had any physical therapy.
Dr. Tierney and myself had a lengthy discussion with Wendy that her noncompliance in the past with physical therapy orders really makes this a difficult case for her. She would likely benefits from a Fulkerson osteotomy to realign the patella, however, this would require extensive physical therapy as well as an extended period of time off of work. Dr. Tierney recommended that we place Wendy in a patellar stabilizing brace, have her get into some formal physical therapy for several weeks. Wendy is in agreement with this plan. If she continues to fail conservative treatment, we would be willing to continue on to surgical intervention.
Wendy would definitely benefit from a Fulkerson osteotomy, however, given her poor compliance in the past with physical therapy we are a little reluctant at this point to proceed. Wendy has agreed to do a more diligent trial of physical therapy at this time and if she does fail this conservative treatment, we could potentially proceed with Fulkerson osteotomy.
¶24 The claimant was off work for a month following her March 17, 2002 accident and then for a period of time only worked part time. (Trial Test. and see Ex. 3 at 3-5.) She testified that she continues to have pain and swelling of her knee and that it often feels like it will “give out” even though she is on her feet no more than prior to the 2002 accident. On the other hand, she testified that her pain and swelling are the same as after the 2001 accident.
I last saw Ms. Lockwood on 4/30/02 for a recurrent dislocation of her right patella. It is common for people who have had dislocations of their patella to have recurrent instability as a result of disruption of the medial retinaculum and overall weakness of the extensor mechanism. I do think her repeat dislocation is a potential natural progression of her 6/20/01 incident. I had not had an opportunity to see Ms. Lockwood back to place her at maximum medical improvement between 7/24/01 and 3/17/02; therefore, I do not know whether she was doing well and not having any problems in that intermediate period. Based on her current findings I do believe it is probably a progression of her previous work related injury and would consider it in that status.
I am responding to your letter dated April 16, 2003, concerning this patient’s Workers’ Comp claim of June 20, 2001. The patient, in my notes, was noted to have had previous right patellar problems, last being noted in February of 1997 by Dr. Robert Stanchfield, and she was referred to Dr. Tierney at that time. She was thought to have had a probable right patellofemoral subluxation with maltracking at that time.
The patient had not had significant symptoms with her right knee again until her injury of June 20, 2001, at the Main Street Convenience. She was seen in my office on June 28 concerning this as she continued to have problems after that injury. She was seen by physical therapy and worked with them concerning her problem.
She had a recurrence of her injury on March 17, 2002, in which she had a patellar dislocation which required manual reduction in the emergency room. I suspected at that time that her injury back in 2001 played a role in the significant dislocation that occurred on March 19 [sic] as the ligaments and tendons which hold the alignment of these bony articulations become progressively more attenuated with each significant injury. The injury of June 20, 2001, was obviously the only significant injury that we have in the record prior [sic] to 1997. I therefore feel that this played a significant role in what now is a worsening patellofemoral tracking problem.
It is still my opinion that the episode of March 17, 2002, was directly related to Wendy’s injury of June 20, 2001, for the above-stated reasons. If you have any further questions concerning this problem, please feel free to contact me.
¶27 As set out in both letters, the causal relationship found by both doctors was in the nature of a predisposition to further incidents of the sort the claimant suffered on March 17, 2002.
made her susceptible to reinjury in March of 2002, which each injury following that is going to make her knee subsequently weaker, more susceptible to dislocation.
That’s what happens with the ligaments, once you damage ligaments, they are never as good as they were initially.
¶29 He also testified concerning two other points critical to the decision in this case: whether the claimant had reached maximum medical improvement (MMI) prior to March 17, 2002, and whether the March 17, 2002 incident materially aggravated her preexisting knee condition.
¶30 With regard to MMI he opined that she had not reached that point prior to March 17, 2002 and testified that it could take up to two years for ligaments and muscles to rebound from the injury, although he said that it would probably take less time with physical therapy and her failure to submit to physical therapy may have delayed MMI. (Rausch Dep. at 11, 25-26). Of significance, he did not identify treatment for claimant’s 2001 injury other than physical therapy.
¶32 Dr. Randale Sechrest examined the claimant at the insurer’s request and also testified by deposition. Dr. Sechrest is a board certified orthopedic surgeon and has performed numerous knee operations. Dr. Sechrest’s speciality encompasses knee injuries such as the claimant’s.
¶36 There are two factual issues which need to be resolved in this case. The first is whether the claimant suffered a permanent, material aggravation of her preexisting knee condition when she dislocated her kneecap on March 17, 2002. If she suffered only a temporary aggravation, then Liberty remains liable for medical expenses and indemnity benefits after the temporary aggravation resolved, i.e., after she returned to baseline. Second, if on March 17, 2002, she suffered a permanent and material aggravation of her preexisting knee condition, had she already reached maximum medical improvement with respect to her June 20, 2001 injury?
¶38 The testimony concerning MMI following the June 20, 2001 injury is conflicting. The claimant’s treating orthopedic physician, Dr. Tierney, declined to render an opinion because he had not seen her between July 24, 2001 and March 17, 2002. (Ex. 3 at 60.) Dr. Rausch opined she had not reached MMI during that interval since she continued to experience problems and it could take, in his opinion, up to two years for full healing of the ligaments and muscles, although he conceded that physical therapy could have accelerated her recovery. Dr. Sechrest opined that even without physical therapy, the claimant should have reached MMI within six weeks and in fact was at MMI prior to March 17, 2002.
¶39a Patellar dislocations fall under the orthopedic speciality. While family physicians are certainly qualified to diagnose and treat the condition, orthopedic surgeons are more qualified to do so.
¶39b The claimant’s patellar dislocation on June 20, 2001, was not as significant as the March 17, 2002 injury and likely did not involve the degree of injury as on March 17, 2002. On June 20, 2001, the dislocated patella spontaneously returned to its normal position within minutes and she did not suffer bruising or ecchymosis, which are the hallmarks of soft tissue tearing.
¶39c The claimant returned to work after a day or two and continued working during the next nine months.
¶39d Between her July 24, 2001 and March 17, 2002 injuries, the claimant did not seek medical care for her knee.
¶39f The claimant did not undertake the physical therapy prescribed by Dr. Tierney following her June 20, 2001 injury. While she testified she did not do so because she needed to continue working and her working precluded her doing physical therapy, I have found that explanation unbelievable in light of the fact that she did not commence work until 2:00 p.m. or 3:00 p.m. in the afternoon, leaving her mornings free to obtain physical therapy. Since her claim was accepted by Liberty that therapy would have been paid for by Liberty. I find it more likely that she did not feel physical therapy was needed or essential, which is another indication that she quickly rebounded from her June 20, 2001 injury and did not suffer any significant lingering problems from it.
¶39g The only treatment prescribed following the claimant’s June 20, 2001 injury was physical therapy and the claimant declined that treatment. Thus as of July 24, 2001 (the date Dr. Tierney prescribed physical therapy), there was no further medical treatment which would improve her condition.
¶40 This case is governed by the 1999 version of the Montana Workers’ Compensation Act since that was the law in effect at the time of the claimant’s industrial accident. Buckman v. Montana Deaconess Hospital, 224 Mont. 318, 321, 730 P.2d 380, 382 (1986).
¶41 It is undisputed that the claimant suffered a patellar dislocation of her right knee on June 20, 2001, and that Liberty accepted liability for that injury. The issue in this case is whether the claimant’s subsequent patellar dislocation on March 17, 2002, relieves Liberty of further liability for the claimant’s patellar condition.
¶42 A template for analysis of the issues in this case is found in this Court’s decision in Patterson v. Montana Contractor Compensation Fund, 1999 MT 158, 295 Mont. 120, 983 P.2d 300. Under the holding in that case, the insurer for an accepted claim must prove that the claimant reached MMI and thereafter suffered a nonwork-related injury to the same part of his body. I follow that template.
Since Liberty accepted liability for the claimant’s June 20, 2001 industrial injury, it bore the burden of proving that the claimant reached MMI prior to March 17, 2002, and that she suffered a further injury to her knee on that date. Chaney v. U.S. Fidelity & Guaranty, 276 Mont. 513, 519, 917 P.2d 912, 915 (1996); and see Patterson, 1999 MT 158, ¶¶ 38-43, 295 Mont. 120, ¶¶ 38-43, 983 P.2d 300, ¶¶ 38-43.
Injuries include material, permanent aggravations of preexisting conditions. § 39-71-407(2)(a)(ii), MCA, and see Patterson, ¶¶ 45-48.
¶45 While the claimant suffered an industrial injury to her right knee on June 20, 2001, I am persuaded in this case, that on March 17, 2002, the claimant suffered a new, material and permanent aggravation of that injury. I refer the reader back to my findings of fact, paragraphs 37 to 39. Liberty has therefore satisfied its burden of establishing a new injury.
“Medical stability”, “maximum healing”, or “maximum medical healing” means a point in the healing process when further material improvement would not be reasonably expected from primary medical treatment.
“Primary medical services” means treatment prescribed by a treating physician, for conditions resulting from the injury, necessary for achieving medical stability.
As set forth in my findings of fact, the only treatment prescribed for the claimant after her 2001 injury was physical therapy, which was available to her but she chose not to pursue. Where a claimant refuses further treatment, MMI has been reached. Hams v. Liberty Northwest Ins. Corp., 2000 MTWCC 6, ¶45; Bustell v. State Comp. Ins. Fund, 2002 MTWCC 18, ¶¶ 57, 62. Moreover, other evidence shows she was medically stable prior to March 17, 2002. I have therefore found as a matter of fact that the claimant reached MMI prior to her March 17, 2002 injuries.
¶46 Since Liberty has satisfied its burden under section 39-71-407(5), MCA, it is not liable for medical or indemnity benefits after March 17, 2002.
¶47 While Liberty is liable for the claimant’s June 20, 2001 industrial injury to her knee, the claimant suffered a subsequent, March 17, 2002 nonwork-related injury to that knee. The subsequent injury relieves Liberty of further liability with respect to the claimant’s June 20, 2001 injuries. The petition is therefore dismissed with prejudice.
¶49 Any party to this dispute may have twenty days in which to request a rehearing from these Findings of Fact, Conclusions of Law and Judgment.
DATED in Helena, Montana, this 2nd day of March 2004.
1 “Dislocate” and “sublux,” and variants of those terms, are used in the medical records. They describe the same thing, i.e., the kneecap going out of its usual anatomical track.

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