Issued by THE LABOR AND INDUSTRIAL RELATIONS ......5, State location where alleged accident occuned or occupational disease contracted: Sikeston, Scott County, Missouri. 6. Was above

Issued by THE LABOR AND INDUSTRIAL RELATIONS COMMISSION

TEMPORARY OR PARTIAL AWARD (Affirming Award and Decision of Administrative Law Judge)

Employee:

Employer:

Insurer:

Carol Caldwell

Unilever USA, Inc.

Insurance Company of the State of Pennsylvania

Injury No. 17-070606

The above-entitled workers' compensation case is submitted to the Labor and Industrial Relations Commission for review as provided by§ 287.480 RSMo, which provides for review concerning the issue of liability only. Having reviewed the evidence and considered the whole record concerning the issue of liability, the Commission finds that the award of the administrative law judge in this regard is supported by competent and substantial evidence and was made in accordance with the Missouri Workers' Compensation Law. Pursuant to§ 286.090 RSMo, the Commission affirms and adopts the award and decision of the administrative law judge dated April 28, 2020.

This award is only temporary or partial, is subject to further order and the proceedings are hereby continued and kept open until a final award can be made. All parties should be aware of the provisions of§ 287.510 RSMo.

The award and decision of Administrative Law Judge Maureen Byrne, issued April 28, 2020, is attached and incorporated by this reference.

Given at Jefferson City, State of Missouri, this -~5=th~ __ day of January 2021.

LABOR AND INDUSTRIAL RELATIONS COMMISSION

;t nejo, Chairman

Reid K. Forrester, Member

Shalonn K. Curls, Member Attest:

~~\\~ Secretary t

Employee: Carol Caldwell Injury No. 17-070606

Employee:

Dependents:

Employer:

Additional Party:

Insurer:

Hearing Date:

ISSUED BY DIVISION OF WORKERS' COMPENSATION

TEMPORARY OR PARTIAL A WARD

Carol Caldwell Injury No. 17-070606

NIA

Unilever USA, Inc.

NIA

Insurance Company of the State of Pennsylvania c/o Broadspire Services, Inc.

January 27, 2020 Checked by: MT/kg

SUMMARY OF FINDINGS

1. Are any benefits awarded herein? Yes.

2. Was the injury or occupational disease compensable under Chapter 287? Yes.

3. Was there an accident or incident of occupational disease under the Law? Yes.

4. Date of accident or onset of occupational disease? August 20, 2017,

5, State location where alleged accident occuned or occupational disease contracted: Sikeston, Scott County, Missouri.

6. Was above employee in employ of above employer at time of alleged accident or occupational disease? Yes.

7, Did employer receive proper notice? Yes.

8, Did accident or occupational disease arise out of and in the course of the employment? Yes.

9, Was claim for compensation filed within time required by law? Yes.

10. Was employer insured by above insurer? Yes.

11, Describe work employee was doing and how accident happened or occupational disease contracted: Employee sustained an accident to the left index finger after over-using her

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left hand, in part, because of pain and limitations related to a separate work injury involving her right upper extremity.

12. Did accident or occupational disease cause death? No.

13. Parts of body injured by accident or occupational disease: Left index finger.

14. Compensation paid-to date for temporary total disability: $0

15. Value necessary medical aid paid to date by employer-insurer? $0

16. Value necessary medical aid not furnished by employer-insurer? $0

17. Employee's average weekly wage: $1,032.37

18. Weekly compensation rate: TTD $688.25

19. Method wages computation: By agreement.

20. Amount of compensation payable:

Unpaid medical expenses: NIA

Additional Medical Aid: See findings.

TTD: NIA

The case was left open in order for the parties to confirm Employee's average weekly wage and temporary total disability rate. The parties confirmed these amounts and the record was closed on January 29, 2020.

This award is only temporary and partial, is subject to further order, and the proceedings are hereby continued and the case kept open until a final award can be made.

IF THIS A WARD IS NOT COMPLIED WITH, THE AMOUNT AWARDED HEREIN MAY BE DOUBLED IN THE FINAL AW ARD, IF SUCH FINAL A WARD IS IN ACCORDANCE WITH THIS TEMPORARY AW ARD.

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Employee: Carol Caldwell Injury No, 17-070606

FINDINGS OF FACT AND RULINGS OF LAW

On, January 27, 2020, the employee, Carol Caldwell, appeared in person and by her attorney, Kimberly A. Beckemeyer, for a temporary or partial award. The employer-insurer was represented at the hearing by their attorney, Christopher D. Vanderbeek. The Court took judicial notice of all of the records contained within the files of the Division of Workers' Compensation, At the time of the hearing, the parties agreed on certain undisputed facts and identified the facts that were in dispute, These undisputed facts and issues, together with a statement of the findings of fact and rulings of!aw, are set forth below as follows:

UNDISPUTED FACTS:

I, Covered Employer: That on or about August 20, 2017, the employer, Unilever USA, Inc., was operating under and subject to the provisions of the Missouri Workers' Compensation Act.

2, Covered Employee: That on or about August 20, 2017, Carol Caldwell was an employee of Unilever USA, Inc, and was working under and subject to the Missouri Workets' Compensation Act.

3. Notice: That the employer had notice of the employee's work injmy that occuned on or about August 20, 2017.

4. Statute of Limitations: That the employee's claim was filed within the time allowed by law.

5. Final award if no medical treatment awarded: That if no further medical treatment is awarded, the Award shall be a Final Award.

6, Average weekly wage and rate: That the average weekly wage is $1,032.37 and the rate for tempora1y total disability is $688.25.

7. Medical aid furnished by Employer-Insurer: That Employer has furnished $0 in medical aid.

8. Temporary disability paid by Employer-Insurer: Temporary total disability benefits have not been paid by the Employer-Insurer.

ISSUES:

1. Accident: On or about August 20, 2017, the employee sustained an accident arising out of and in the course of her employment.

2. Medical Causation: Employee's injury was medically causally related to accident or occupational disease.

3. Future Medical Aid: Employee is making a claim for additional or future medical aid.

EXHIBITS

The following exhibits were offered and admitted into evidence:

Employee's Exhibits I, Dr, Bruce Schlafly's Report 2. Dr. Bruce Schlafly's Addendum with 287,210 letter attached

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3. Deposition of Dr. Bruce Schlafly 4, Medical Records

(A) Missouri Delta Physician Services, Dr. Bernardo (B) Advanced Bone and Joint, Dr. Frisella (C) Missouri Delta Medical Center (D) Restart (E) Motion Orthopaedics, Dr. Milne

Employer-Insurer's Exhibits A. Deposition of Carol Caldwell B. Deposition of Dr. Shawn Kutnik C. Updated Note of Dr. Shawn Kutnik

STATEMENT OF THE FINDINGS OF FACT AND RULINGS OF LAW:

STATEMENT OF THE FINDINGS OF FACT-

Employee's testimony

Employee, Carol Caldwell, is a 55-year-old single individual. Employee graduated high school in 1982. That same year she began working at Brown Shoe Company as a machine operator, a job she held until 1994, cutting shoe patterns. She did not have any workers' compensation claims while in that employment.

In 1994 Employee began working for Unilever and she has worked there continuously since that time. For a period of time in the early 2000s, Employee worked part-time at Casey's making

. pizzas. She held that job for about five years, working three days per week. She also stocked the kitchen. She was not injured while in that employment.

Employee began with Unilever as a hand packer at the south plant of the company in Sikeston, Missouri. Work as a hand packer involved packing ice cream, taking "bad bars" off the line using her hands. She also put ice cream bars in boxes. She was in this position for about three years. While in this position, she injured her left index finger, sustaining a fracture to the fingertip. She had a fixation surgery with placement of a pin, then removal of that pin, and she eventually received a settlement through workers' compensation. From that time until August 2017, she did not have any problems with the left index finger.

In the late 1990s or early 2000s, Employee took a position with Unilever as a wrap operator. This involved placing wrap in machines, monitoring wrap machines, and monitoring hand packers. At one point, Employee sustained a neck injury while working in this position. She underwent a surgery for this injury and later received a settlement.

In the mid-2000s, Employee took a position as an operator in which she was in charge of the whole wrap machine and the workers operating it. Initially, this was at the south plant; she moved to the north plant in Sikeston in 2015. While still at the south plant, she started having

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problems with her right shoulder, which she reported to Unilever. Those problems continued after she moved to the north plant and through 2017.

At the north plant, Employee continued working as an operator. This required many activities such as pulling pallets, cleaning machines, drawing mix and making mix. Pallets contained ingredients. Using a hand-operated pallet jack, she would move a pallet full of boxes to her workstation, and then she worked with the boxes, weighing 30-40 lbs, each. She typically did two pallets per shift. Then the machine was cleaned and scrubbed with brushes and foamers, and then it was put back together again. Drawing mix involved dumping product into the machine. Typically this was done about six times per day, Making mix involved adding flavor to mix. She also had to do paperwork every 30 minutes, indicating flavor that was brought to the floor, with recording of product weights as well. Product was weighed manually on a scale.

From 2015 to 2017, Employee's work included "changeovers," where one machine was switched out for a different machine. This process involved replacing pipes and tubes. Employee used her left hand more than her right during this period due to the injury to her right shoulder. The only tools she used for this process were screwdrivers, pliers and occasionally hammers. She described the changeover process as the most physically demanding process of her employment. The number of times this process was done per shift varied.

From April 2017 through August 2017, Employee continued to have right shoulder pain, making it difficult to work and causing her to favor her left upper extremity, including on August 20, 2017. She was ultimately diagnosed with a work-related rotator cuff tear, and to date, she has undergone three surgeries as a result of that condition.

On August 20, 2017, Employee began her shift in the morning finishing a changeover, and ultimately she performed three changeovers during this shift. She described this as an "unusually high" number of changeovers, and this date of work more physically strenuous than a typical day. She removed 30-40 clamps per changeover. The clamps are about 1.5" in size and made of metal and have to be twisted into and out of place. On this date she was primarily using her left hand to do this work because of the pain in her right shoulder.

Employee indicated that she did not notice anything unusual about her left hand on August 20, 2017. Employee says that the following morning that her left finger was "stuck" and that she reported this injury to her employer the following day. She described the left index finger as being swollen and painful and testified that she was unable to straighten the left index finger without manually bending it back into place with her other hand. Employee testified she did not have any left index finger complaints of stiffness, swelling, pain, inability to straighten her finger, or popping of the joint before this injury.

Employee testified that she was sent to Dr. Bemardo for medical treatment in August 2017. She said that Dr. Bernardo ordered an X-ray and-ultimately told her that she had arthritis.

Employee testified that at that point she sought legal representation. Employee testified that in September 2017 she met with and retained Kimberly A. Beckemeyer of Burns, Taylor,

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Employee; Carol Caldwell Injury No. 17-070606

Heckemeyer, Green & Edwards, LLC to pursue medical treatment for her left index finger on her behalf.

After Employee retained counsel, she testified that she was sent back to Dr. Kutnik by her employer for evaluation on or about January 10, 2018, and that he opined that her left index finger injury was not work related.

Employee testified her attorney then sent her to Dr. Bruce Schlafly for evaluation in May, 2018. She testified that Dr. Schlafly diagnosed her with a partial tear of her sagittal band in her left index finger and that he recommended a surgical c011'ection,

Employee testified that on September 23, 2.019, her employer then sent her back once again to Dr. Kutnik. She said that he examined her and that she reported to Dr. Kutnik the symptoms she was having at the time. It was Employee's testimony that Dr. Kutnik told her during that office visit that her symptoms had become worse since her last visit with him in January 2018.'

Employee testified that the condition of her left index finger has negatively impacted her daily life. It was her testimony that she now has trouble combing her hair, opening a can of soda, zipping her pants, making a fist and opening doors. Employee testified that although she has worked, except during the periods that she was off following her shoulder surgeries, her pain level in her left index finger remains approximately an eight. Employee testified that her symptoms have continued to worsen with time.

Employee testified that she has no hobbies outside of work and that she has not injured her left index finger since the date of injury either at work or outside of work. She requested that the employer be ordered to provide further medical treatment for her left index finger as recommended by Dr. Bruce Schlafly.

Employee's deposition

Employer offered Employee's deposition which was talcen November 22, 2017. On that date Employee testified that she is single, has lived in the same house for 28 years and does not take part in any hobbies, exercise, aits or crafts, She testified that she has no criminal history, does not drink alcohol and takes prescription medication only for blood pressure, hormones and ulcers. Employee testified she has a 12th-grade education but no education beyond high school.

Employee testified that her right shoulder problems began prior to February 2017 and that her right shoulder pain was reported to her employer. She testified she had prior neck injury at Unilever for which she underwent surgery as well as a prior finger injury that also required surgery,

Employee testified that she broke the "top bone" of her left index finger when her finger was hit by a frozen ice cream bar and that she had two surgeries as a result thereof. Employee said that the first surgery resulted in the insertion of a pin into the finger and the second surgery removed the pin. She testified that following the second surgery of her finger, she had no problems with the left index finger,

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Employee testified during her deposition that she has worked for Unilever continuously since 1994 and that other than the times that she had been off of work related to her prior work injuries, she had not missed work for any reason.

Employee testified that she has been an operator doing manual labor on the line for the past approximate 17 years, As part of this manual labor she said she:

• Does "changeover" of molds which means that the operator changes the machine from producing one type of product to another.

• Uses a crane to move "big bowls" then picks them up manually and puts them on top of a "big machine."

• Pours mix into the hopper, • She said approximately monthly that the hoppers that must be lifted to perform the

"change over" must be lifted chest high; that they weigh about 300 pounds and takes two workers to do.

When asked specifically of what her daily work consists of, she stated she has had to:

• Bring in supplies, put supplies onto a cart then push them to the production floor. • Pull supplies manually from a pallet, place them on a cart then push them to the

production floor. • Lift and carry some supplies in five-gallon buckets. • Lift boxes of sticks into a machine that feeds sticks into the popsicles. • Push 55-gallon drums of flavoring.

Employee testified as to the method of completing a "changeover". Employee testified that a changeover can take between one to four hours to complete, or it could take an entire shift to complete the cleaning pa1t of a changeover, depending upon what product is being produced. She testified a changeover you screw on and off clamps, break clamps loose, clean the machine with scrubbers; basically you take the machine apart, clean the parts, then put it back together with different parts. She said sometimes they may run for three days without a changeover then on some days they may only run a few hours before they have to shut the machine down to start a changeover.

Employee testified that the day before her left index finger "looked up" she went in ''finished cleaning up, finished taking a machine apa1t, put it back together, ran four hours, took it back down and put it back together again in a 12-hour shift." She said she repmted it and was sent to Dr. Bernardo.

Employee's right shoulde1· treatment

Employee testified she sustained an injury to her right shoulder that was initially reported to her employer in 2015 but that she did not receive treatment for the injury to her right shoulder until

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2017. Employee testified that from 2017 to 2019 her pain level in her right shoulder has been severe.

In April 2017 Employee was sent to Dr. Shawn Kutnik for medical treatment for her right shoulder. Employee testified that Dr. Kutnik gave her an injection in her right shoulder and told her she needed an appointment with a surgeon who specialized in shoulder treatment.

Employee was then sent to Dr. Frisella in June 2017 for medical treatment regarding her right shoulder injury. Employee testified that Dr. Frisella opined that the right shoulder injury was not a work-related injury.

Employee was then sent to Dr. Milne for medical treatment. Employee testified that Dr. Milne stated that her right rotator cuff was torn and indicated she needed surgery. Dr. Milne performed Employee's first right shoulder surgery. However, she still had severe right shoulder pain following the procedure.

Employee was then sent to Dr. Nogalski for medical treatment. Employee testified that Dr. Nogalski has performed two right shoulder surgeries since he began treating her for her work-related right shoulder injury.

Employee's Medical records

Medical Records from Dr. Bernardo:

In his August 25, 2017 office note, Dr. Bernardo stated that Employee was "right handed, She does work for Unilever as a Machine Operator for about 23 years. She works production at 'Telente Line'. She does work 12 hour work shift from 6 AM to 6 PM ... she uses her both hands. She does gripping for tightening clamps using her both hands."

Dr. Bernardo opined that, "at this point in time, Ms, Caldwell's condition is NON-OCCUPATIONAL" and Employee was released on regular activity as of August 25, 2017.

Medical Records from Dr, Frisella:

On June 14, 2017, Employee saw Dr, Frisella for an evaluation of her right shoulder, which she said had persisted since approximately 20 l 5.

Following a right shoulder MRI, Dr. Frisella noted that Employee had a degenerative rotator cuff tear and stated that in his opinion the rotator cuff tear was not work related,

Medical Records from Missouri Delta Medical Center:

Employee had an MRJ of her right shoulder March 28, 2017, which diagnosed a full-thickness right rotator cuff tear.

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Medical Records from Restart:

Restart of Sikeston provided Employee physical therapy from March, 2017 through May, 2017. Physical therapy and in-home exercise programs were required to address the problems of Employee's right shoulder.

Medical records from Motion Orthopaedics, Dr. Milne:

Employee saw Dr. Michael Milne initially on November 6, 2017, pertaining to her right shoulder injury; Dr. Milne performed a rotator cuff repair on February 21, 2018.

Dr. Bruce Schlafly

Employee saw Dr. Bruce Schlafly on May 1, 2018, for an independent medical exam. Dr. Schlafly's deposition was taken on November 29, 2018. Dr. Schlafly wrote an addendum to his IME report on April 10, 2019. In his report Dr. Schlafly noted Employee expressed problems with her left index finger. Specifically, he noted Employee's abnormal popping involving the extensor tendon of the left index finger at the level of the proximal (MCP) joint.

Dr. Schlafly reviewed with Employee her medical history. It is noted in the report that Employee had previously suffered a right shoulder injury, occun'ing in 2015, and that in 2017 she had limited use of her right aim as a result. Employee also disclosed she had a prior work-related injury to the distal joint of her left index finger, Employee indicated there was a fracture in the area of the distal joint of her left index finger that required pinning to repair. Employee later had the pin removed, Dr. Schlafly noted that Employee reported no residual problems in the index finger after the pin was removed.

Employee gave Dr. Schlafly an account of the events occurring on the date of injury, August 20, 2017. Employee explained to the doctor that she had a strenuous twelve-hour shift, in which it was necessary to complete three changeovers. Dr. Schlafly noted that Employee "must take her machine apart and clean it, and she says that the work is hand intensive, because she must loosen and tighten numerous metal clamps using her hands, and she says she uses tools such as screwdrivers and wrenches". Additionally, the doctor notes that Employee was relying heavily upon her right hand due to her previous shoulder injury.

Employee informed Dr. Schlafly she experienced symptoms following her shift on August 20, 2017, and repotted the injury to her supervisor via telephone the following day.

Dr. Schla:fly reviewed Employee's medical records from both Dr. Bemardo and Dr. Kutnik and conducted an office exam, Dr, Schlafly noted that Employee has "limited ability to raise her right arm, but good range of motion in the right hand without any abnormal triggering or popping involving the flexor or extensor tendons" and that Employee "does not show obvious arthritic changes in her fingers and thumbs of either hand". Dr. Schlafly noted that Employee has a scar on her left index finger from her previous surgery and further noted that she is:

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Employee: Carol Caldwell Injmy No. 17•070606

"nontender at the distal joint of her left index finger. She can demonstrate flexion and extension of the fingers of the left hand, but almost every time she makes a tight fist with the fingers of the left hand, the extensor tendon of the index finger snaps in a radial direction across the dorsum of the MCP joint, due to symptomatic subluxation of the extensor tendon, which is a condition that results when there has been a stretch or tear injury of the sagittal band, which is the tendonous structure that normally maintains an extensor tendon in a centralized position across the dorsum of the MCP joint of a finger."

Dr. Schlafly notes that Employee's "active range of motion of the left index finger is Oto 80 degrees at the proximal (MCP) joint, 0 to 90 degrees at the middle joint, and 20 to 30 degrees at the previously injured and operated distal joint". "In her normal right index finger, she measures 0 to 70 degrees at the proximal joint, 0 to 90 degrees at the middle joint, and Oto 50 degrees at the distal joint".

At the time of her visit, Dr. Schlafly conducted an X•ray where he states the left hand and left index finger show ''vittually normal MCP joints without any significant aiihritis". The doctor does note that the X·ray shows "moderate a1thritic changes at the PIP joint of the left index fmger and moderately severe aithritis at the distal joint of the left index finger". Dr. Schlafly went on to state "I do not see any arthritic changes at the proximal joint of the left index finger that would create problems with the extensor tendon or sagittal band".

Dr. Schlafly opined that Employee has a "tear (partial or complete) of the sagittal band at the proximal joint of the left index finger, creating painful subluxation of the extensor tendon". He recommended surgery to repair the sagittal band to stabilize the extensor tendon in a centralized position across the MCP joint.

Dr. Schlafly stated in his report that he believes Employee's left index finger injury at the proximal joint is a result of her work injury dated August 20, 2017. The doctor reports it is his belief the prevailing factor in the cause of injury was Employee's repetitive gripping and twisting with the left hand during the course of her employment at Unilever.

The addendum of Dr. Bruce Schlafly addresses correspondence sent from Employee's attorney, inquiring about X·rays conducted by Dr. Shawn Kutnik at Archway Orthopedics and Hand Surgery. Dr. Schlafly remarked that the discs from Dr. Kutnik's office are "excellent. I think that they are of somewhat high quality than the x.rays taken on the digital mini C·arm machine at my office .. .''

Dr. Schlafly analyzed the X-rays from Dr. Kutnik's office and states, "I do not see significant aiihritis at the metacaipophalangeal (abbreviated as MCP or MP) joint of the foUI' fingers. There are well•preservedjoint spaces at all four of the MCP joints of the fingers. The X·rays do show moderate aithritic changes at the middle (PIP) joint of the left index finger and moderately severe arthritis at the distal (DIP) joint of the left index finger. I do not see any arthritic changes at the proximal (MCP) joint of the left index finger that would create problems with the extensor tendon or sagittal band."

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Dr. Schlafly states his diagnosis of Employee remained the same after reviewing the Dr. Kutnik X-rays, and that Employee's left index finger injury is due to a work-related tear of the sagittal band of the left index finger. Fmther, Dr. Schlafly states in the addendum that surgery is required to repair the tear.

Dr. Schlafly testified that he only performs one to two sagittal band repair surgeries per year and further stated that this pmticular diagnosis is uncommon.

Dr, Schlafly testified that in connection with his evaluation, he inquired of Employee of her medical history and he read Employee's deposition, The doctor noted that at the time he saw her, Employee "complained about abnormal popping involving the proximal joint of the left index finger, which she called her knuckle in her deposition".

Dr. Schlafly testified that Employee disclosed her occupational history. The doctor noted that Employee has "been working as a machine operator at an ice cream factory, and she's been working there for 24 years." Further, he noted that Employee claimed "she developed this particular problem after working an unusually difficult 12-hour shift in August 2017."

The doctor noted that the events of August 20, 2017, were relevant to his evaluation of Employee. Dr. Schlafly stated it was relevant because Employee "is normally right-handed but at the time of the injury, she had to rely to a greater extent upon her left hand due to problems with her right shoulder, and I think that it was an unusual repetitive stress with her left hand on the day of injury,"

When asked about Employee's prior injuries to her left index finger, the doctor testified that Employee had indeed sustained a prior injury to the distal joint of her left index finger that required pinning. However, Employee told the doctor she had no pain in her left index finger following the injury.

During her appointment Employee reported to Dr. Schlafly that following her shift (on August 20, 2017) she woke up the following morning with her knuckle "popping" and that it has persisted since,

Dr. Schlafly conducted a physical evaluation of Employee during her appointment, The doctor testified that Employee "has limited ability to taise her right arm at the shoulder. At the left, almost every time she makes a tight fistwith the fingers, the extensors tendon of the index finger snaps in a radial direction across the dorsum of the MCP joint. In other words, symptomatic subluxation occurs."

During the physical evaluation, the doctor measured range of motion in the left and right index fingers. The doctor testified, "she measured zero to 80 degrees of motion at the MCP joint of the left index finger, which is actually a bit more than what I measured at the same joint of the normal right index finger, I measured zero to 90 degrees at the middle joint of the left index finger, with motion at the distal joint of that finger ranging only from 20 to 30 degrees."

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Dr. Schlafly testified that he perfotmed a test on Employee by asking her to form a fist with her left hand. When Employee tightly formed a fist, the doctor was able to visualize the tendon snapping. Nonnally when this test is preformed, the sagittal bands keep the extensor tendon in a central location rather than falling off the top of the joint into the valley between the joints.

The doctor preformed X-rays of Employee's left hand. The doctor testified that Employee does not have rheumatoid arthritis. However, the doctor did testify that Employee has "some arthritis in her left index finger. Specifically, that she has moderately severe at the PIP joint and moderately severe at the distal joint, At the MCP joint of the left index finger, I did not think it was significant, but I would characterize what's there as mild, in tenns of arthritis," The doctor then confirmed that Dr. Kutnik also characterized the MCP joint arthritis as mild.

The doctor then testified he recommended further treatment for Employee, Specifically, he recommended a repair of the left index finger sagittal band. He states that the subluxation is substantial and he would recommend immediate treatment.

When asked about the causation of the injury, the doctor testified it is his belief that Employee's 12-hour shift on August 20,2017, caused Employee's condition and need for treatment. Dr, Schlafly stated he believes "repetitive gripping and twisting with the left hand at work, is the prevailing factor in the cause of the torn sagittal band with the extensor tendon subluxation."

On cross-examination Dr. Schlafly agreed that there had been progression of the trauma to the sagittal band enhancing the subluxation from when Dr. Kutnik examined Employee to her appointment with Dr. Schlafly.

Dr. Kutnik

Employee saw Dr. Kutnik for an independent medical exam on January 10, 2018. Dr. Kutnik prepared an addendum report on October 1, 2018, after reviewing Dr. Schlafly's May 1, 2018 IME report, Furthermore, Dr. Kutnik's deposition was taken on April 2, 2019.

During the independent medical exam, Employee repo1ted to Dr. Kutnik that after a regular shift in August 2017 she woke up the following morning with swelling and pain in het' left index finger, with no "real trauma that she could relate," but "heavier lifting, more so than normal," a day earlier, She complained of"locking down" in the finger, with additional "moderate overall aching." Employee told Dr. Kutnik that this occurred "in August 2017." In his examination, Dr, Kutnik noted slight subluxation of the extensor tendon over the joints of the index finger, without full dislocation. Employee was able to fully move the joint, and there were no complaints of specific pain. Dr. Kutnik confirmed Employee did not describe a specific injury to the finger.

In his January 10, 2018 examination, Dr. Kutnik obtained X-rays on a digital machine, which ·provides greater detail of the bones than a fluoroscopic C-arm X-ray machine. In his digital X-rays, Dr. Kutnik noted ruthritic changes to the metacarpophalangeal (MPM) joint, the same area where Employee's complaints were localized,

Page 12


Dr. Kutnik noted that Employee estimated 30 clamps had to be unfastened as part of this process, with loosening and removal of pipes during the changeover process. Dr. Kutnik also reviewed an examination note from Dr. Bernardo dated August 25, 2017, wherein he noted complaints of stiffness in the index finger that Dr. Bernardo deemed non-occupational.

Dr. Kutnik diagnosed symptomatic arthritis in the left index finger, based on Employee's description of her complaints, his examination findings and his X-ray findings. He opined that the described activities in August 2017 were not the prevailing factor underlying his diagnosis, based on the a1thritic condition being chronic and degenerative, not caused by repetitive use or heavy use, leading Dr. Kutnik to conclude that the condition was "age-related wear." Dr. Kutnik noted that he found a slight subluxation of the extensor tendon over the MP joint, which caused the popping Employee experienced at this time.

In Dr. Kutnik's October I, 2018 addendum, he noted that Dr. Schlafly saw a more significant subluxation of the extensor tendon, whereas Dr. Kutnik had found only a slight subluxation less than four months earlier. He noted Dr. Schlafly's examination findings of snapping across the dorsum of the joint resulting in a symptomatic subluxation. He also noted Dr. Schlafly's X-ray findings ofno significant arthritis, and his diagnosis of a work-related subluxation of the tendon due to a sagittal band tear. Dr. Kutnik noted that Dr. Schlafly's findings differed from his January 2018 evaluation, as he did not see as significant a subluxation of the tendon, and also he noted his X-ray findings differed from Dr. Schlafly's. He stated explicitly that he disagreed with Dr. Schlafly's assessment ofX,rays showing normal MCP/MP joints in the left hand. He maintained his prior opinion regarding his diagnosis and his assessment that Employee's work activities were not the prevailing factor in causing that diagnosis.

Dr. Kutnik stated that, typically, that aspect of the joint is rounded, but with early onset arthritis it "starts to become more of a sharper angle." He also noted a finding of i1Tegularity at the end of the bone, with altered contour to the head of the metacaipal "consistent with some changes in the alignment of the joint." He discussed further that one of the causes of extensor tendon subluxation is malalignment of the joint, because this causes the balance of the tendon to be thrown off from what is normal, with the tendon slipping off in either direction with flexion of the finger. This Jed Dr. Kutnik to conclude: "It was reasonable to assume progression of that extensor tendon subluxation as he found in his report, but still doesn't change the underlying diagnosis of arthritis."

Dr. Kutnik opined that no fu1ther or future treatment was needed to cure and relieve the effect of a work-related injury, given his non-work-related diagnosis. He also discussed that traumatic sagittal band rupture typically is seen in the context of a single event with "sudden forceful extension," which was not described by Employee in this case. Typically, Dr. Kutnik sees this condition result from a person having "flicked something rather forcefully," with an immediate feeling of a pop followed by swelling a11d pain. Thereafter, the tendon is "very clearly displaced or subluxed over the top of the finger," and the patient has trouble straightening the finger from a bent position. There is another version of sagittal band deformity, Dr. Kutnik explained, resulting from attritional wear over the course of time, typically seen in the setting of joint malalignment with tendons that are not centrally localized, resulting in extra stress on the tendons. Dr. Kutnik stated that, in the setting of an acute sagittal band rupture, symptoms would

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Employee: Carol Caldwell Injury No, 17-070606

arise iromediately; and attritional wear sagittal band hTegularity could produce symptoms over a course of months or years.

Dr. Kutnik opined that a sagittal band rupture would not occur in the setting of a 12-hour shift of work. He confirmed that he did not believe Employee's job activities on a particular day of August 201 7 caused a sagittal band rupture, for which Dr. Schlafly recommended treatment.

Dr. Kutnik testified that arthritis causes inflaromation and swelling and leads to wearing of the joint, resulting in the overlying tissues rubbing awkwardly, especially in the presence of mala!ignment of the joint. This causes the balance of the tendons to be off and can lead to hTitation in the affected area,

Dr. Kutnik testified consistently with Dr, Schlafly as to the uncommon nature of the sagittal band repair procedure. He also confamed that he evaluated and lhnitedly treated Employee for a right shoulder injury in April 2017, for which he gave an opinion that repetitive use of her upper extremities in her employment with Unilever was the prevailing factor in causing a rotator cuff tear. He also confirmed that he referred Employee to a shoulder surgeon for treatment of that condition,

Dr. Kutnikagreed that, when one upper extremity is restricted, the patient would possibly put strain on the opposite extremity to compensate, and he would have expected Employee to rely more on her left upper extremity when limited with respect to the right upper extremity. Dr. Kutnik confirmed that he had no indication that Employee had any complaints with respect to the left hand when he saw her in April of 2017, but he noted that he did not ask her about the left hand at that time.

Dr. Kutnik agreed that a pattial or complete tear of the sagittal band in the MP joint could cause a painful subluxation of the extensor tendon; however, he disagreed that making a gripping motion entails movement of the sagittal band across the MP joint. He testified affilmatively that this does not happen but, rather, the sagittal band stabilizes the tendon on either side, to create a balance for the tendon as it slides over the tip of the knuckle - the sagittal band does not move during this process, but rather suppo1ts the tendon. He explained that the sagittal band and the extensor tendon are two different anatomical units. He also disagreed with.the possibility that repetitive gripping could cause a pa1tial or complete tear of the sagittal band. Elaborating, he reaffirmed that with gripping and squeezing, sagittal bands stay in place to hold the tendon straight, such that a sagittal band rupture would not make sense with this mechanism, even repetitively.

Further, Dr. Kutnik testified that Employee did not have a rupture of the sagittal band when he examined her in January 2018; rather, there was merely mild subluxation of the extensor tendon over the joint, with the underlying defect being malalignment of the joint causing stress to the sagittal band due to inappropriate positioning of the extensor tendon as a result of that malalignment. He agreed that surgical stabilization of the sagittal band would be the recommended procedure to treat the condition diagnosed by Dr. Schlafly.

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Dr. Kutnik confinned that he did not have any information as to hand-intensive hobbies Employee did outside of work leading up to the alleged injury. He reaffirmed that he did not agree with Dr. Schlafly's diagnosis from May 1, 2018, even though he respects Dr. Schlafly as a surgeon.

On redirect examination, Dr. Kutnik reaffirmed that he disagreed with Dr. Schlafly's diagnosis with respect to the left index finger MP joint, with Dr. Kutnik noting a subluxation secondary to aiihritis versus Dr. Schlafly diagnosing a subluxation secondary to rupture of the sagittal band. Further, he reaffirmed that in January 2018 he did not visual or objectively find any evidence of a sagittal band ruptme in the MP joint.

RULINGS OF LAW:

Issue 1. Accident; Issue 2. Medical Causation; and Issue; 3. Employee's claim for additional or future medical aid.

Employee's testimony indicates that on August 20, 2017, Employee's work was more physically strenuous than a typical day because there was a high number of"changeovers." On this date, she was primarily using her left hand to do this work because of the pain in her right shoulder.

Employee stated that she did not notice anything unusual about her left hand on August 20, 2017; however, the following morning, Employee's left finger was "stuck" and that she reported this injury to her employer the following day. She described the left index finger as being swollen and painful and testified that she was unable to straighten the left index finger without manually bending it back into place with her other hand. Employee testified she did not have any left index finger complaints of stiffness, swelling, pain, inability to straighten her finger, or popping of the joint prior to August 20, 2017.

It is undisputed that:

• Employee had no hobbies outside work that entailed the repetitive use of her upper extremities.

• Employee had no left index finger pain, popping or abnormal symptoms prior to August 20, 2017.

• Employee had to use hand tools to clamp and unclarnp pa1ts of the machines; she had to push and pull, lift and carry throughout the course of her work day.

It is further undisputed that:

• Employee had a right rotator cuff tear and further undisputed that the pain from that torn right rotator cuff had caused her to seek treatment for that condition of her right shoulder through her employer in 2017.

• When Dr. Kutnik saw Employee in April 2017, he limited her use of her right upper extremity because of that right rotator cuff teai·.

• Employee is right hand dominant.

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• The first report or medical document that references that Employee's left index finger was symptomatic at the MCP joint was in August 2017.

Dr. Schlafly and Dr. Kutnik have differing opinions regarding whether Employee sustained a work-related injury, ·

Dr, Schlafly opined that Employee has a "tear of the sagittal band at the proximal joint of the left index finger, creating painful subluxation of the extensor tendon",

Dr. Schlafly stated in his report that he believes Employee's left index finger injury at the proximal joint is a result of her work injury dated August 20, 2017. The doctor reports it is his belief the prevailing factor in the cause of injury was Employee's repetitive gripping and twisting with the left hand during the course of her employment at Unilever. He recommended surgery to repair the sagittal band to stabilize the extensor tendon in a centralized position across the MCP joint.

Dr. Schlafly analyzed the X-rays from Dr, Kutnik's office. He stated that he did not see any arthritic changes at the proximal (MCP) joint of the left index finger that would create problems with the extensor tendon or sagittal band,

Dr. Kutnik diagnosed symptomatic arthritis in the left index finger. He opined that the described activities in August 2017 were not the prevailing factor underlying his diagnosis based on the aiihritic condition being chronic and degenerative, not caused by repetitive use or heavy use, leading Dr. Kutnik to conclude that the condition was "age-related wear." Dr, Kutnik noted that he found a slight subluxation of the extensor tendon over the MPjoint, which caused the popping Employee experienced at this time.

An "accident" under the Missouri Workers' Compensation Act is an unexpected traumatic event or unusual strain identifiable by time and place of occurrence and producing at the time objective symptoms of an injury caused by a specific event during a single work shift,

Employee was having to rely primarily on her non-dominant hand to use hand tools and perfonn her job, There is no evidence that prior to this injury that she had any symptoms of the left index finger, Employee did not realize she had sustained an injury until the next day; however, the injury occm1'ed the day before on a "single work shift," Based on all of the evidence presented, including Employee's credible testimony, I find the opinion of Dr, Schlafly is more persuasive than the opinion ofKutnik on the issues of accident and medical causation,

I find that on or about August 20, 2017, Employee sustained an ac.cident arising out of and in the course of her employment. I find that Employee has sustained the burden of proof that the injury to her left index finger is medically, causally related to the accident that occu!1'ed on August 20, 2017. Fulihermore, I find that Employee's accident on August 20, 2017, was the prevailing factor in causing her to develop the defect of the sagittal band of her left index finger.

Based on all of the evidence presented, I find that Dr. Schlafly' s opinion, regarding the issue of additional medical treatment, is credible, I find Employee needs additional medical care and

Page 16


tl'eatment that flows from the accident. I find that Employee is in need of additional medical care and treatment to the left index finger to relieve her from the effects of the August 20, 2017 work accident and injury.

Employer-Insurer is ordered to provide Employee with all of the medical care that is reasonable and necessary to cure and relieve her from her work-related injuries to her left index finger pursuant to section 287.140 RSMo including, but not limited to, treatment as recommended by Schlafly,

ATTORNEY'S FEE:

Kimberly A. Heckemeyer, attorney at law, is allowed a fee of25% of all sums awarded under the provisions of this award for necessaiy legal services rendered to Employee. The amount of this attorney's fee shall constitute a lien on the compensation awarded herein.

INTEREST:

Interest on all sums awarded hereunder shall be paid as provided by law,

As previously indicated this is a temporary or partial award. The award is therefore subject to further order, and the proceedings are hereby continued and the case kept open until a final award can be made.

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Employee: Carol Caldwell

I certify that on L/ -J//-J.,D I delivered a copy of the foregoing award lo the parties lo the case, A cornpleta record _of the method of deliveiy and data of service upon each party Is retained with the executed award in the Division's case file.

By __ ..,£.,M-"'"-fJL.11/ __ _

Injmy No. 17-070606

Made by:

Maureen Byrne FKA "Maureen Tilley" Administrative Law Judge

Division of Workers' Compensation

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CJ

Documents

Issued by THE LABOR AND INDUSTRIAL RELATIONS ......5, State location where alleged accident occuned or occupational disease contracted: Sikeston, Scott County, Missouri. 6. Was above