In re Compensation of Oates, 070319 ORWC, 17-03500

Docket Nº:WCB 17-03500
Case Date:July 03, 2019
71 Van Natta 703 (2019)
In the Matter of the Compensation of WILLIAM T. OATES, Claimant
WCB No. 17-03500
Oregon Worker Compensation
July 3, 2019
          Jodie Phillips Polich, Claimant Attorneys           Tolleson Conratt Nielsen et al, Defense Attorneys           Reviewing Panel: Members Curey, Lanning, and Wold.           ORDER ON REVIEW          Claimant requests review of Administrative Law Judge (ALJ) Martha Brown's order that upheld the self-insured employer's denial of claimant's injury claim for a right foot/ankle condition. On review, the issue is compensability. We reverse.          FINDINGS OF FACT          We adopt the ALJ's "Findings of Fact" with the following supplementation.          On June 21, 2017, claimant sought treatment for right leg and foot swelling that began the day before. (Exs. A1-A5). Right foot x-rays showed normal alignment and no fractures or dislocation, but noted degenerative changes. (Ex. A4). Claimant was diagnosed with edema and elevated blood glucose. (Ex. A2-3).          On June 28, 2017, claimant, a furniture mover, was moving a heavy chair down a flight of stairs with a coworker when they became out of sync and claimant was bumped backwards down the steps. (Tr. 8, 16). He initially did not drop the chair but then was bumped backwards again, and the chair struck a wall and the top of his right foot. (Tr. 8-9, 17, 20-23). Claimant was able to finish the job, but did not walk backwards because his right foot hurt. He took the rest of the day off. (Tr. 9-10, 18). He tried to work the next day, but left early because the pain in his right foot was excruciating. (Tr. 10-12, 18).          On July 1, 2017, claimant went to the emergency room for right foot pain, reporting that he repeatedly twisted his right foot carrying a chair downstairs with a coworker, which caused him to go backwards missing a step. (Exs. 2-1, 3). He reported having had immediate pain, but that he was able to finish working. (Id.) His examination findings included swelling, edema, and numbness. (Exs. 2-2, 3, 4). X-rays [71 Van Natta 704] showed a complex fracture/dislocation of the tarsometatarsal junction. (Ex. 4). A CT scan showed significant fracture deformity with dislocation at the tarsometatarsal joint. (Ex. 5). An attempt to reduce the dislocation was unsuccessful, and claimant was transferred to another facility. (Ex. 3-2).          On June 2, 2017, Dr. Tomczak, a podiatrist specializing in foot/ankle surgeries, noted that claimant was diabetic and sustained a work-related injury and fall resulting in a traumatic dislocation of his right midfoot. (Exs. 9-1, 34, 44). Her preoperative examination demonstrated an unstable displaced midfoot dislocation with concern for overlying soft tissue swelling, which she diagnosed as a traumatic acute right midfoot dislocation. (Ex. 9-1). Given the nature of claimant's injury and the extent of soft tissue swelling, Dr. Tomczak recommended staged surgical intervention, performing a temporary reduction and fixation that day, to be followed by reconstruction. (Id.) Her postoperative diagnosis was a right traumatic acute dislocation of the midfoot with underlying Charcot neuroarthropathy. (Exs. 9-1, 19-1, 24-1).          On July 17, 2017, the employer denied claimant's right foot/ankle injury claim. (Ex. 22). Claimant requested a hearing.          On July 19, 2017, Dr. Tomczak performed right midfoot arthrodesis and fixation surgery, noting findings consistent with early degenerative changes consistent with Charcot neuroarthropathy, as well as "acute dislocation" findings. (Ex. 25-2). She diagnosed a right midfoot traumatic dislocation with neuropathy. (Ex. 25-1).          On October 13, 2017, Dr. Mangum, an internal medicine specialist who examined claimant at the employer's request, diagnosed complicated and uncontrolled diabetes, including peripheral neuropathy and neural arthropathy with Charcot joint, and probable nephropathy. (Ex. 36A1-6). Dr. Mangum deferred the questions concerning Charcot foot to the orthopedic provider that claimant was scheduled to see the next day, but explained that individuals with uncontrolled diabetes often have neuropathy, as well as "neuroarthropathy and this combination of collapse and dislocation and fractures of bones in the foot known as Charcot foot or Charcot arthropathy." (Ex. 36A1-7). He stated that he has had patients with the condition occurring without injury, which he believed was "far more common and a problem that happened gradually as the foot and bone change due to the pathology and complications of the underlying diabetes." (Id.) Dr. Mangum opined that claimant's Charcot foot was a preexisting condition. (Id.)          [71 Van Natta 705] Dr. Mangum attributed claimant's Charcot foot to his underlying uncontrolled diabetes and its complications, rather than the reported work incident. (Id.) He considered the "post-injury" imaging studies to be consistent with a process that developed over a long period, and not the single work event. (Ex. 36A1-8). Dr. Mangum found no condition attributable to claimant's work injury and no evidence of a preexisting condition combining with the injury, but could not completely rule out "some combining or minor component of work, or some degree of work aggravating or contributing to some extent to this problem." (Id.) Although considering a combined condition to be unlikely, Dr. Mangum stated that the work injury would not be the major contributing cause of claimant's problem. (Id.)          On October 14, 2017, Dr. Fellars, an orthopedic surgeon who examined claimant at the employer's request, diagnosed preexisting right foot Charcot arthropathy, multiple right midfoot fracture dislocations secondary to the preexisting Charcot arthropathy, a work-related right foot contusion by history, a likely Charcot process in the left foot, and poorly-controlled diabetes. (Ex. 37-11). Dr. Fellars stated that claimant's work injury did not cause the right foot fracture dislocations, and that the fracture dislocations were due to Charcot neuroarthropathy as a sequela of his diabetes. (Ex. 37-12-17).          According to Dr. Fellars, Charcot foot is either due to dysregulation of blood flow from neuropathy resulting in significant fracture dislocations inconsistent with minor trauma, or due to microtrauma over time that would stop a normal individual from walking, but continues in a progressive pattern in individuals who have neuropathy from diabetes because they do not have protective sensation in their feet. (Ex. 37-12, -15). Dr. Fellars opined that significant trauma is not required to cause fractures and dislocations for individuals with Charcot neuroarthropathy from diabetes. (Ex. 37-12-17). He stated that a "normal foot does not fall apart as the X-Ray reports describe without significant trauma[,]" and described claimant's reported mechanism of injury to be 'very low-energy." (Ex. 37-16).          Dr. Fellars considered it medically probable that, despite the severity of his x-ray findings, claimant was walking around for several days after the injury due to his lack of protective sensation from his diabetes and resultant Charcot condition, which confirmed that his diabetes caused the findings seen in the July 2017 imaging studies. (Id.) He noted that he had seen many individuals with "horrific-looking x-rays" who did not know they had a significant problem because their foot did not hurt due to neuropathy and diabetes. (Ex. 37-16, [71 Van Natta 706] -18-19). Dr. Fellars concluded that claimant's preexisting conditions did not combine with his work injury because the injury did not cause any significant damage to the foot, and that the major contributing cause of claimant's need for treatment was the preexisting Charcot condition. (Ex. 37-17).          After reviewing claimant's imaging studies, Dr. Fellars explained that a critical evaluation of the June 21, 2017, x-ray showed findings consistent with an early stage 1 Charcot process, and that the July 1, 2017, x-ray findings were "well into the fragmentation stage[,]" which strengthened his previous opinion that claimant's fractures and dislocations were due to the preexisting Charcot process from diabetes. (Ex. 41-6-7). He did not consider the work injury to be traumatic enough to cause fractures or dislocations in a normal foot, and stated that it was not medically probable that claimant would be able to continue working without significant pain after his injury if the injury actually caused the July 1, 2017, findings, "unless the process was Charcot and not trauma." (Ex. 41-10).          Based on his interaction with individuals who have no history of trauma but develop Charcot arthropathy...

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