{"id":"full_commission-H103763-2023-04-04","awcc_number":"H103763","decision_date":"2023-04-04","opinion_type":"full_commission","claimant_name":"Elizabeth Salto","employer_name":"University Of Arkansas Fayetteville","title":"SALTO VS. UNIVERSITY OF ARKANSAS FAYETTEVILLE AWCC# H103763 APRIL 4, 2023","outcome":"unknown","outcome_keywords":[],"injury_keywords":["fracture","back","neck","lumbar"],"pdf_url":"https://labor.arkansas.gov/wp-content/uploads/Salto_Elizabeth_H103763_20230404.pdf","source_index_url":"https://labor.arkansas.gov/workers-comp/awcc-opinions/full-commission-opinions/","filename":"Salto_Elizabeth_H103763_20230404.pdf","text_length":22898,"full_text":"BEFORE THE ARKANSAS WORKERS' COMPENSATION COMMISSION \n \n \nCLAIM NO.  H103763 \n \nELIZABETH SALTO, \nEMPLOYEE \n \nCLAIMANT \nUNIVERSITY OF ARKANSAS FAYETTEVILLE,  \nEMPLOYER \n \nRESPONDENT \nPUBLIC EMPLOYEE CLAIMS DIVISION, \nINSURANCE CARRIER/TPA \nRESPONDENT \n  \n      \nOPINION FILED APRIL 4, 2023 \n \nUpon review before the FULL COMMISSION in Little Rock, Pulaski County, \nArkansas. \n \nClaimant represented by the HONORABLE EVELYN E. BROOKS, Attorney \nat Law, Fayetteville, Arkansas. \n \nRespondents represented by the HONORABLE CHARLES H. McLEMORE, \nJR., Attorney at Law, Little Rock, Arkansas. \n \nDecision of Administrative Law Judge:  Reversed. \n \n \n OPINION AND ORDER \n The claimant appeals an administrative law judge’s opinion filed July \n27, 2022.  The administrative law judge found that the claimant failed to \nprove she was entitled to additional medical treatment.  After reviewing the \nentire record de novo, the Full Commission reverses the administrative law \njudge’s opinion.  We find that the claimant proved she was entitled to \nadditional medical treatment in accordance with Ark. Code Ann. §11-9-\n508(a)(Repl. 2012).       \nI.  HISTORY \n\nSALTO - H103763  2\n  \n \n \n Elizabeth Salto, now age 43, testified that she became employed as \na custodian for the respondent-employer, University of Arkansas, in 2018.  \nThe parties stipulated that the employee-employer relationship existed on \nFebruary 12, 2021, on which date the claimant “sustained a compensable \ninjury to her tailbone (coccyx fracture).”  The claimant testified that she \nslipped on ice and fell on her buttocks.       \n According to the record, the claimant treated at Arkansas \nOccupational Health Clinic on February 22, 2021: \nAt the request of and authorization by University of Arkansas, \nwe are seeing Elizabeth Salto.... \nPatient states she was going to the building to start her duties.  \nShe states she slipped on ice and fell down the stairs onto her \nbottom.  She states she is having pain in the bottom, lower \nback and neck.... \nFaded bruising is present to left Sacrum.... \n \n Amanda Bell, APRN diagnosed “1.  Sacrum/Coccyx contusion.”  Ms. \nBell planned conservative treatment.    \n An MRI of the claimant’s pelvis was taken on March 17, 2021 with \nthe impression, “Focal edema involving the tip of the coccyx, consistent with \nan acute nondisplaced fracture.”   \n It was planned in part on March 18, 2021, “She agrees to Physical \nTherapy referral to help with her low back and sacral pain & improve her \nfunctioning.”   \n\nSALTO - H103763  3\n  \n \n \n An investigator with Meridian Investigative Group performed \nsurveillance of the claimant on four dates beginning April 21, 2021.  The \ninvestigator concluded, “The claimant appeared to move in a fluid, \nunrestricted manner.  No visible braces or supports were observed.”   \n Dr. Mark Miedema reported on April 29, 2021: \nMrs. Salto presents for evaluation of 2-1/2 months low back \nand tailbone pain.  She had a work-related injury on \n2/12/2021.  She had a slip and fall onto her back and buttock \nand fell down about 3 steps which precipitated her symptoms.  \nShe was not having pain prior to this incident.  She has been \ngoing to physical therapy, exercising at home, taking \ngabapentin and methocarbamol.   \nOn my review of her pelvic MRI done at Mana on 3/17/2021 \nthat showed edema within the tip of the coccyx consistent with \nan acute nondisplaced fracture.... \nI educated the patient on conservative treatment options \nincluding physical therapy, home exercise program, healthy \ndiet and lifestyle, acupuncture, massage, chiropractic care, \npharmacotherapy and injections.   \nI encouraged her to continue with physical therapy and home \nexercising is already in progress.   \nShe has [an] acute nondisplaced coccyx fracture as result of \nher work injury.  I encouraged her this should continue to heal.  \nThese typically take 6 to 12 weeks to heal.  I am hopeful that \nin another month she will be feeling almost back to normal.   \nGiven the severity of the patient’s pain and functional \nlimitation and no relief or inability to tolerate conservative \nmeasures, we will proceed with a ganglion impar block for \ndiagnostic and therapeutic purposes.   \nI do not yet think she has reached maximal medical \nimprovement.  She may return to work next week with no \nrestrictions.  I do not expect this injury to result in a permanent \nimpairment or require surgery.  I think she will have reached \nMMI in approximately one more month.   \nI will plan to follow-up with this patient after this procedure to \nreassess their progress.   \n \n\nSALTO - H103763  4\n  \n \n \n Dr. Miedema assessed “1.  Low back pain,” “2.  Pain in the coccyx,” \nand “3.  Fracture of coccyx.”    \n Dr. Miedema performed a Lumbar Sympathetic Ganglion Impar \nBlock on July 1, 2021.  The claimant testified on cross-examination that she \ndid not benefit from this procedure.   \n An MRI of the claimant’s pelvis was taken on July 26, 2021 and was \ncompared with the March 17, 2021 study: \nThere are a few well-circumscribed fat intensity lesions within \nthe sacrum and right ilium, the largest of which measures 1.1 \ncm.  The previously seen focal edema at the tip of the coccyx \nhas resolved.  No evidence of a fracture is seen.... \n  IMPRESSION:  1.  No evidence of a fracture is seen.   \n \n The claimant followed up with Dr. Miedema on August 5, 2021: \nMrs. Salto presents for follow-up evaluation of 5.5 months low \nback and tailbone pain.  To review she had a slip and fall \nwhile at work on 2/12/2021 which precipitated her symptoms.  \nShe has been going to physical therapy, exercising at home, \ntaking gabapentin and methocarbamol without relief.  She is \nhere to review recent MRI.   \nOn my review of her pelvic MRI done at Ozark on 7/24/2021 \nthis was normal with resolution of the edema previously seen \nat the tip of the coccyx and no evidence of fracture.  To review \npelvic MRI done at Mana on 3/17/2021 showed edema within \nthe tip of the coccyx consistent with an acute nondisplaced \nfracture.... \nI encouraged her to continue with physical therapy and home \nexercising is already in progress.... \nShe had a nondisplaced coccyx fracture as result of her work \ninjury.  I encouraged her this is healed [on] her most recent \nMRI.   \nShe is s/p a ganglion impar block on 7/1/21 with unfortunately \nlimited relief.  I encouraged her she will continue to improve \n\nSALTO - H103763  5\n  \n \n \nwith time.  I will refill her methocarbomol as an adjuvant for \npain relief and muscle spasms.   \nI think she has reached maximal medical improvement.  I do \nnot think this injury has caused permanent impairment.  She \nmay continue to work with no restrictions.   \nI will follow-up with her as needed.   \n \n Dr. Kenton Hagan examined the claimant on September 8, 2021: \nThe patient complains of sacrococcygeal joint pain, stiffness, \nand weakness.  It is constant, sharp, stabbing, tender to \ntouch, and numbing pain.  The symptoms are 7 out of 10 \ncurrently.  The symptoms have been present for 8 months.  \nThe symptoms have been treated with epidural steroid \ninjection and physical therapy.  The condition is worse with \nsitting, worse with standing, worse during the day, and worse \nduring the night.... \nImpression/Plan:   \nPain over coccyx after fall at work.   \nPrior epidural and MRI with Dr. Miedema at Ozarks.  MRI and \nrecords are not available to review. \nDoes not want another injection due to pain of procedure. \nDiscussed options and agree to Celebrex and starting pelvic \nPT (Charla Cox).   \n \n The claimant testified on direct examination: \nQ.  We have [Dr. Hagan’s] records in evidence and they seem \nto reflect that he wanted you to have some pelvic physical \ntherapy.  Is that correct? \nA.  That is correct.   \nQ.  And was that the same type of physical therapy you had \nhad before? \nA.  No. \nQ.  Were you able to have that physical therapy? \nA.  I went about two to three times and then they said that \nthey were not going to cover it anymore. \nQ.  Okay.  And in that therapy, what were you doing? \nA.  She was teaching me breathing methods, meditating to \nease the pain.  I had to do some exercises.  Like with \ntouching, she tried doing stuff and I couldn’t do the touching at \nthat point, so we were going to work towards where I was \n\nSALTO - H103763  6\n  \n \n \nokay where she could touch, but I didn’t get to finish my \ntreatment.   \nQ.  Did you get to return to Dr. Hagan? \nA.  They said I couldn’t go back.     \n  \nThe record contains a Change of Physician Order dated September \n10, 2021:  “A change of physician is hereby approved by the Arkansas \nWorkers’ Compensation Commission for Elizabeth Salto to change from Dr. \nMark Miedema to Dr. Kenton Hagan[.]”   \nThe claimant treated with a physical therapist, Jacquelynn M. \nSaravane on September 21, 2021 and September 24, 2021.    \nThe claimant visited telephonically with Dr. Francisco Avalos, La \nSagrada Familia Medical Clinic, Cicero, Illinois, on October 2, 2021.  Dr. \nAvalos diagnosed “Chronic coccyx fracture pain please excuse!  Myalgia, \nweakness, ambulatory difficulty, lower limb pain.”   \nThe claimant followed up with Dr. Avalos on October 7, 2021. \nThe claimant treated with Ms. Saravane on October 15, 2021.     \nDr. Avalos’ recommendation on November 2, 2021 was a “Neurology \nconsult.”   \nDr. Avalos diagnosed the following on January 22, 2022:  “Coccyx \nfracture...Please removal (sic) all restrictions (work).  Patient is doing \nbetter.”      \nA pre-hearing order was filed on April 13, 2022.  The claimant \ncontended, “The claimant contends she is entitled to receive additional \n\nSALTO - H103763  7\n  \n \n \nmedical treatment by her authorized treating physician.  The claimant \nreserves all other issues.”   \n The respondents contended, “The respondents contend the claimant \nreported having a fall injury on February 12, 2021 which has been accepted \nas compensable and that the claimant has been provided all benefits to \nwhich she is entitled for her fractured coccyx tailbone injury.  The \nrespondent has provided claimant with medical treatment reasonable and \nnecessary for the compensable injury, including March 17, 2021 and July \n26, 2021 MRI studies, and treatment with Dr. Mark Miedema who treated \nthe claimant conservatively.  Dr. Miedema reviewed both MRI studies and \nreleased the claimant at maximum medical improvement on August 5, 2021 \nwith 0% permanent impairment.  The respondent was provided by \nrespondent her one time change of physician with Dr. Kenton Hagan, whom \nshe saw on September 8, 2021.  Dr. Hagan did not take claimant off work.  \nThe claimant was paid temporary total disability benefits from April 12, 2021 \nuntil May 2, 2021, at which point Dr. Miedema released the claimant to \nreturn to work without restrictions on May 3, 2021.  The claimant \nsubsequently resigned February 28, 2022.”   \n The parties agreed to litigate the following issue:  “1.  Claimant’s \nentitlement to additional medical treatment.”   \n\nSALTO - H103763  8\n  \n \n \n A hearing was held on July 11, 2022.  The claimant testified on direct \nexamination: \n  Q.  How are your symptoms now? \nA.  I am still in pain.  It hurts to sit, to stand.  I just have to be \nmoving from side to side and stuff and I need to take breaks \nand sit down.  But I mean I am not dying, but it is bothering \nme.   \nQ.  And since the accident happened, have you had any new \ninjuries to your back or your buttocks? \nA.  No, ma’am. \nQ.  And what about any improvement, have you ever \ncompletely gotten better during this time? \nA.  No.   \nQ.  What is it that you want from this hearing? \nA.  I just want to continue the sessions I was doing with the \npelvic therapist because she was promising so many things \nand I was really, really looking forward to that and Dr. Hagan \nsaid, also, he wanted to do more things to see and just I want \nto get better.  I just want treatment.   \n \n An administrative law judge filed an opinion on July 27, 2022 and \nfound that the claimant failed to prove she was entitled to additional medical \ntreatment.  The administrative law judge therefore denied and dismissed \nthe claim.  The claimant appeals to the Full Commission. \nII.  ADJUDICATION \n The employer shall promptly provide for an injured employee such \nmedical treatment as may be reasonably necessary in connection with the \ninjury received by the employee.  Ark. Code Ann. §11-9-508(a)(Repl. 2012).  \nThe employee has the burden of proving by a preponderance of the \nevidence that medical treatment is reasonably necessary.  Stone v. Dollar \n\nSALTO - H103763  9\n  \n \n \nGeneral Stores, 91 Ark. App. 260, 209 S.W.3d 445 (2005).  Preponderance \nof the evidence means the evidence having greater weight or convincing \nforce.  Metropolitan Nat’l Bank v. La Sher Oil Co., 81 Ark. App. 269, 101 \nS.W.3d 252 (2003).  What constitutes reasonably necessary medical \ntreatment is a question of fact for the Commission.  Wright Contracting Co. \nv. Randall, 12 Ark. App. 358, 676 S.W.2d 750 (1984).     \n An administrative law judge found in the present matter, “2.  \nClaimant has failed to meet her burden of proving by a preponderance of \nthe evidence that she is entitled to additional medical treatment for her \ncompensable injury.”  The Full Commission does not affirm this finding. \n The parties stipulated that the claimant sustained a compensable \ninjury to her tailbone in the form of a coccyx fracture on February 12, 2021.  \nThe claimant testified that she slipped on ice and fell.  The evidence \ndemonstrates that the claimant has suffered from significant and chronic \npain as result of the compensable injury.  An APRN diagnosed \n“Sacrum/Coccyx contusion” on February 22, 2021 and the claimant was \ntreated conservatively.  An MRI of the claimant’s pelvis on March 17, 2021 \nshowed \"Focal edema involving the tip of the coccyx, consistent with an \nacute nondisplaced fracture.”  The claimant was initially referred to physical \ntherapy on March 18, 2021.   \n\nSALTO - H103763  10\n  \n \n \n Dr. Miedema correctly noted on April 29, 2021 that the claimant “was \nnot having pain” prior to the compensable injury.  Dr. Miedema planned in \npart, “I encouraged her to continue with physical therapy and home \nexercising is already in progress.”  The claimant testified that she did not \nbenefit from an injection performed by Dr. Miedema on July 1, 2021.  The \nfindings from an MRI on July 26, 2021 included the following:  “The \npreviously seen focal edema at the tip of the coccyx has resolved.  No \nevidence of a fracture is seen....IMPRESSION:  1.  No evidence of a \nfracture is seen.”   \n On August 5, 2021, Dr. Miedema reported that he had reviewed the \nJuly 2021 diagnostic study.  Dr. Miedema opined, “I think she has reached \nmaximal medical improvement.”  The Full Commission interprets Dr. \nMiedema’s August 5, 2021 report to indicate that the claimant had reached \nthe end of her healing period for the February 12, 2021 compensable injury.  \nNevertheless, it is well-settled, established law that a claimant may be \nentitled to ongoing medical treatment after the healing period has ended, if \nthe medical treatment is geared toward management of the claimant’s \ninjury.  Patchell v. Wal-Mart Stores, Inc., 86 Ark. App. 230, 184 S.W.3d 31 \n(2004), citing Hydrophonics, Inc. v. Pippin, 8 Ark. App. 200, 649 S.W.2d \n845 (1983). \n\nSALTO - H103763  11\n  \n \n \n Although he opined that the claimant in the present matter had \nreached maximal medical improvement no later than August 5, 2021, Dr. \nMiedema also plainly stated, “I encouraged her to continue with physical \ntherapy and home exercising is already in progress.”  Dr. Hagan began \ntreating the claimant on September 8, 2021.  Like Dr. Miedema, Dr. Hagan \nrecommended continued physical therapy.  Dr. Hagan specifically planned \n“pelvic PT (Charla Cox).”  The claimant testified that the respondent-carrier \nallowed her to receive some physical therapy before controverting \nadditional treatment.  The claimant received a statutory Change of \nPhysician to Dr. Hagan on September 10, 2021, after the claimant’s first \nvisit with Dr. Hagan on September 8, 2021.  The respondents do not \ncontend that any of the claimant’s treatment of record, including treatment \nwith Dr. Hagan, was unauthorized in accordance with Ark. Code Ann. §11-\n9-514(c)(3)(Repl. 2012).   \n The record indicates that rather than treating with Charla Cox as \nrecommended by Dr. Hagan, the claimant treated with Jacquelynn M. \nSaravane beginning September 21, 2021.  The claimant testified that she \nbenefitted from physical therapy provided by Ms. Saravane.  The claimant \ntestified that she simply wished to receive additional physical therapy in \naccordance with the recommendation of Dr. Hagan.  The claimant bears the \nburden of proving that she is entitled to additional medical treatment.  Ark. \n\nSALTO - H103763  12\n  \n \n \nHealth Ctr. v. Burnett, 2018 Ark. App. 427, 558 S.W.3d 428.  The Full \nCommission finds in the present matter that the claimant proved additional \nphysical therapy was reasonably necessary in connection with her \ncompensable injury. \n After reviewing the entire record de novo, the Full Commission finds \nthat the claimant proved she was entitled to a program of physical therapy \nas recommended by Dr. Hagan.  The claimant proved that said treatment \nwas reasonably necessary in accordance with Ark. Code Ann. §11-9-\n508(a)(Repl. 2012).  For prevailing on appeal to the Full Commission, the \nclaimant’s attorney is entitled to a fee of five hundred dollars ($500), \npursuant to Ark. Code Ann. §11-9-715(b)(2)(Repl. 2012).   \n IT IS SO ORDERED.        \n \n    ___________________________________ \n    SCOTTY DALE DOUTHIT, Chairman \n \n    ___________________________________ \n    M. SCOTT WILLHITE, Commissioner \n \n \nCommissioner Mayton dissents. \nDISSENTING OPINION \n I must respectfully dissent from the Majority opinion finding that the \nclaimant has proven by a preponderance of the evidence that she is entitled \n\nSALTO - H103763  13\n  \n \n \nto additional medical treatment resulting from her February 12, 2021 \ncompensable injury. \nThe question at hand is not simply whether a treating physician \nfound that additional treatment was necessary for a claimant’s recovery. \nWhen assessing whether medical treatment is reasonably necessary, we \nmust analyze both the proposed procedure and the condition it is sought to \nremedy.  Deborah Jones v. Seba, Inc., Full Workers’ Compensation \nCommission Opinion filed December 13, 1989 (Claim No. D511255). \nTreatments to reduce or alleviate symptoms resulting from a compensable \ninjury; to maintain the level of healing achieved; or to prevent further \ndeterioration of the damage produced by the compensable injury are \nconsidered reasonable medical services.  Foster v. Kann Enterprises, 2009 \nArk. App. 746, 350 S.W.2d 796 (2009).  That being said, any liability for \nadditional medical treatment may extend beyond the healing period but \nmust be geared toward the management of the compensable injury. \nPatchell v. Wal-Mart Stores, Inc., 86 Ark. App. 230, 184 S.W.3d 31 (2004). \nWhat constitutes reasonably necessary medical treatment is a question of \nfact for the Commission.  Wright Contracting Co. v. Randall, 12 Ark. App. \n358, 676 S.W.2d 750 (1984).  However, the Commission may not arbitrarily \ndisregard medical evidence.  Pyle v. Woodfield, Inc., 2009 Ark. App. 251, \n306 S.W.3d 455 (2009).  The Commission also has the duty of weighing the \n\nSALTO - H103763  14\n  \n \n \nmedical evidence as it does any other evidence, and resolving any conflict \nis a question of fact for the Commission.  Crow v. Weyerhaeuser Co., 46 \nArk. App. 295, 880 S.W.2d 320 (1994) (citing Chamberlain Group v. Rios, \n45 Ark. App. 144, 871 S.W.2d 595 (1994)).  However, the Commission is \nnot bound by medical opinion, although it may not arbitrarily disregard the \ntestimony of any witness.  It is also entitled to examine the basis for a \ndoctor's opinion in deciding the weight to which that opinion is entitled. Id. \n(citing Reeder v. Rheem Mfg. Co., 38 Ark. App. 248, 832 S.W.2d 505 \n(1992)). \n On April 29, 2021, the claimant was referred to orthopedist Dr. Mark \nMiedema. Dr. Miedema concluded that the claimant had not reached MMI, \nbut that he did not expect her injury to result in permanent impairment or \nrequire surgery.  (Resp. Ex. 1, P. 32).  Dr. Miedema recommended a \nganglion impar block at that time. Id.  At the April 29, 2021 visit, Dr. Midema \nreleased the claimant to work full duty on May 3, 2021 and opined that she \nwould reach MMI in approximately one month. Id.  On July 15, 2021, Dr. \nMiedema examined the claimant, ordered an MRI, and once again released \nthe claimant to work without restriction.  (Resp. Ex. 1, P. 40).  The results of \nthe MRI on July 26, 2021 showed that “the previously seen focal edema at \nthe tip of the coccyx has resolved. No evidence of a fracture is seen.” \n(Resp. Ex. 1, P. 43).  On August 5, 2021, Dr. Miedema “encouraged her \n\nSALTO - H103763  15\n  \n \n \n[the nondisplaced coccyx fracture] is healed on her most recent MRI.” \n(Resp. Ex. 1, P. 50).  Dr. Meidema released the claimant at maximum \nmedical improvement with no permanent impairment on August 5, 2021. Id.  \nThe claimant was later evaluated by Dr. Kenneth Hagan using her \none-time change of physician through the Commission.  She was only seen \nby Dr. Hagan one time and he noted in his report that he did not have Dr. \nMiedema’s findings to review.  (See Resp. Med. Ex., P. 53).  The claimant \ntestified that she later visited with Dr. Francisco Avalos by phone on two (2) \noccasions but never saw him in person and was never examined or treated \nby him.  (Hrng. Trans., Pp. 21-22). \nDr. Miedema’s findings bear greater weight than the opinions of \neither Dr. Hagan or Dr. Avalos.  Dr. Miedema is an orthopedic specialist \nand is the only physician who treated, examined, and tested the claimant \nnumerous times.  Further, Dr. Miedema reviewed the results of the July 26, \n2021 MRI showing that the fracture was healed while neither Dr. Hagan nor \nDr. Avalos accessed or reviewed those records.  In fact, Dr. Avalos, a \ngeneral practitioner, never met with the claimant in person and Dr. Hagan \nonly saw her one time. \nBased upon the facts presented, the claimant’s testimony, and \nreports from the treating physicians and physical therapist, Dr. Mark \nMiedema’s opinion must bear the greatest weight.  After reviewing two \n\nSALTO - H103763  16\n  \n \n \nMRIs nearly six months after the claimant’s injury, Dr. Miedema determined \nthat the claimant did not need any additional medical treatment and was \ncapable of full duty work with no restrictions.  The ALJ’s findings were \ntherefore well-reasoned. \nFor these reasons, I respectfully dissent.   \n                                                                      \n    ___________________________________ \n    MICHAEL R. MAYTON, Commissioner","preview":"BEFORE THE ARKANSAS WORKERS' COMPENSATION COMMISSION CLAIM NO. H103763 ELIZABETH SALTO, EMPLOYEE CLAIMANT UNIVERSITY OF ARKANSAS FAYETTEVILLE, EMPLOYER RESPONDENT PUBLIC EMPLOYEE CLAIMS DIVISION, INSURANCE CARRIER/TPA RESPONDENT OPINION FILED APRIL 4, 2023","fetched_at":"2026-05-19T22:29:46.488Z","links":{"html":"/opinions/full_commission-H103763-2023-04-04","pdf":"https://labor.arkansas.gov/wp-content/uploads/Salto_Elizabeth_H103763_20230404.pdf","source_publisher":"https://labor.arkansas.gov/workers-comp/awcc-opinions/full-commission-opinions/"}}