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Moreno v. Menlo Logistics12/27/2000
Argued and submitted March 14, 2000.
WOLLHEIM, J.
Reversed and remanded for reconsideration.
Claimant seeks review of an order of the Workers' Compensation Board reversing an order of the Administrative Law Judge (ALJ) and upholding employer's denial of a claim for low back strain due to lack of proof of medical causation. We reverse the Board and remand the case for reconsideration.
The facts, for purposes of the issues presented for review, are largely undisputed. The Board found that claimant fell at work on April 21, 1998, when his right foot caught on the lip of a trailer that he had been unloading and his left leg went down in the space between the dock and the trailer. On April 22, 1998, claimant sought treatment at an urgent care clinic for complaints of pain involving the upper back, neck, and lower back. On a Form 827, filed with employer on April 22, claimant described his symptoms as "back of my neck left side and lower back hurt." Claimant again visited the urgent care clinic on April 27, 1998, and the admitting nurse wrote: "Was in on 4/22 with neck and back injury . Neck pain improved but continues to have left lower back and hip pain." The physician noted on the same form that claimant " ad neck, shoulder stiffness that has improved with rest." The physician noted that claimant reported "lumbar pain with numbness left lat thigh and painful gait." The doctor diagnosed "lumbar strain with left radiculopathy."
Claimant saw Dr. Pierson on April 29, 1998, who noted that claimant had reported falling at work and straining his neck. "He was seen in the Urgent Care the same day and was mainly complaining of left neck and upper back pain." Pierson further reported:
"The neck gradually improved, however, over the ensuing days he has developed pain in the low back and around the left hip area with numbness in the anterior left thigh. * * *
"Presently, he continues to have numbness in the anterior left thigh, but no real radiation of pain down the leg. He basically points around the left hip region as the area of discomfort and toward the low back."
Pierson diagnosed a cervical strain, lumbar strain, and probable hip strain. Neither the ALJ nor the Board described in detail the medical record before claimant's visit to Pierson, other than to note that " he diagnoses made at the urgent care facility were cervical strain (trapezius) and lumbar strain."
On May 5, 1998, claimant gave a statement to an investigator for employer's insurer, saying that immediately after falling he felt a little bit of pain in the hip at the outside surface, but that at night after the fall he experienced "shocking pain" on the inside of his hip. He made no mention of neck or low back pain. On May 8, 1998, employer denied a claim for low back injury , stating that " here is insufficient evidence that your employment at Menlo Logistics either caused or contributed to your low back condition."
Claimant testified at the August 10, 1998, hearing regarding his symptoms immediately after the fall:
"Q: All right. Can you tell us the kind of problems you were having at that time?
"A: Mainly it was the soreness of my hip and--from the impact, it was probably with--probably three or four days my neck was hurting, but mainly, mainly was my--my injury on my--on my--on my hip."
The Board understood claimant's testimony to be inconsistent with his description of the injury given earlier to Pierson. It accepted claimant's testimony as the definitive description of his symptoms.
In discussing the question of medical causation, the Board noted that Pierson had
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