This MKC nurse review highlights the importance of the MOI with the injuries in a trip and fall claim. It also shows the importance of establishing a claimant’s history and its relevance to the claim.
The review involved the case of a 73-year-old female with an extensive past history of degenerative joint disease, allegedly injured when she tripped and fell. The associated medical records show that the claimant complained of pain in her neck, back and right shoulder and was treated by orthopedic providers for over a year and a half. This treatment included numerous imaging studies, physical therapy and, eventually, a total right shoulder joint replacement.
The claimant alleged that all treatment — including her joint replacement surgery – were needed as a result of this fall. There was no demand letter.
The event and injury
The claimant reported that she tripped on a hose and fell in a store, landing onto her knees and then onto her outstretched right hand. She was able to get up on her own and she did not seek immediate medical treatment.
Mechanism of Injury (MOI)
In this fall, the primary impact was to her bilateral knees and then a secondary impact to the right hand/wrist. It is important to note that is not an MOI that would typically cause injury to the shoulder, as the claimant alleges.
The MKC nurse reviewer raised another MOI-related red flag. According to the review of the records, the claimant provided other, varying descriptions of the MOI to different providers, including tripping and falling on her right side, falling on hands and knees, and falling and bracing herself with her wrist.
Moreover, it was noted by the nurse reviewer that the claimant did not seek immediate medical evaluation and that her initial presentation two days later did not include any objective signs of right shoulder impairment/trauma/decreased function. While the claimant did have bilateral knee abrasions consistent with falling onto her knees, she had full range of motion with minimal discomfort.
Comparison of Pre and Post Date of Loss Records
Even though no pre-DOL records were included for review, MKC’s nurse reviewer noted three sets of data points in the pre and post DOL records relevant to the claim:
- Post-DOL records revealed that the claimant had an extensive, multi-year history of degenerative joint disease.
- Her history included acute bilateral shoulder bursitis, prior rotator cuff dysfunction (shoulder in question) for at least five years prior to the DOL, general arthritis, and cervical myelopathy.
- The claimant was the primary caregiver to her disabled husband, who required assistance with activities of daily living and mobility.
The nurse reviewer noted four significant inconsistencies indicating that the need for a complete shoulder replacement would be related to pre-existing, severe degenerative arthritis.
- The MOI does not align with the claimant’s expanding, subjective complaints. Falling on her knees would mean that her knees took most of the impact in the fall. Using her hand to brace herself could injure her wrist, but resulted in limited energy to the shoulder.
- She did not present with signs of acute right shoulder injury and was noted to have full range of motion and minimal discomfort even three days post-DOL. She did not begin to complain of severe shoulder pain and problems with function until more than a week later.
- Imaging studies were positive for severe degenerative arthritis in the right shoulder joint and noted wearing on the undersurface of the acromion.
- Her extensive history of degenerative joint disease was noted to be “end-stage” by one of her providers.
- Of interest, the claimant did not pursue ANY treatment to knee or wrist, other than initial evaluation and limited follow-up for soft tissue complaints.
The claimant’sMOI details did not support acute injury to shoulder, but were consistent instead with soft tissue/abrasions to bilateral knees. The objective, clinical data in the medical records did not support any acute right shoulder joint injury which mitigated the allowable medicals in this case.
The treatment recommended included initial medical exam and short-term follow up visits. It’s important to note that pre-DOL records would have been helpful in this case, considering the claimant’s long history of arthritis and prior issues with her shoulder.
The major take away in the review and analysis of this case is that the MOI must align with the alleged acute pathologies. While injuries can exacerbate or aggravate pre-existing conditions, the resulting treatments need to be supported by objective data points that are consistent with the events in question.