To whom It may concern,

The claimant was seen in the office of Mercer-Bucks Orthopedics for purposes of performing an Independent Medical Examination.
Prior to the exam, the nature of the evaluation and the fact that no doctor/patient relationship exists was explained.

History:

This 52-year-old right-hand dominant female states that on June 21, 2023, she was a restrained driver, wearing her seatbelt, on her way home when it was raining, and a car hit her essentially head-on. It was a multi-car event, with one car hitting another, causing them to spin into her. Her airbag deployed. She had pain in her back and her left hand. She denies any loss of consciousness. She went to Jefferson Washington Hospital by ambulance, had x-rays and CT scans done, and was discharged.

At the time of the accident, she was already under the care of a pain management doctor at Relievus for a previous accident and she saw them within a few days. She was under care due to low back and left knee pain. She had previously had therapy, a spinal stimulator and some injections in the back. She had some numbness and tingling in her back, some pain in her left hip and knee. She had MRIs and is currently still under treatment with physical therapy. She is taking ibuprofen and a muscle relaxant.

The first accident, causing the need for the pain management treatment was in 2018, when she was still under care at the time of the 2023 accident.
After the accident of 2023, her symptoms, including her back pain, got much worse. The tingling in her leg got worse. Her neck was hurting her, but has eased up considerably over the past several months.

Treatment included physical therapy, chiropractic care, acupuncture, several epidurals, the first of which helped, the second did not. She had a couple trigger point injections before Thanksgiving. She is not currently getting chiropractic care.

Medications:

Medications include Zanaflex, Motrin and vitamins.

Occupation:

She is a retail manager and did not miss any work as a result of the accident.

Current Symptoms:

Back pain. She cannot lift or stand/sit for long periods of time. She had another MRI of her back which showed a bulging disc. She has some intermittent pain radiating into her left leg on the outside, and the bottom of her foot intermittently gets numb.

Past Medical History:

Her past history is positive for a right knee scope, November 2025, and a left knee scope several years ago.

Physical Examination:

Physical examination reveals a 52-year-old 5’7” female in no acute distress.

Her neck is supple, nontender, full range of motion, no localized spinous or paraspinal tenderness. Negative Spurling maneuver.

Upper extremity exam reveals full range of motion of the shoulder, elbow and wrist, 5/5 strength all muscle groups with intact sensation. Tinel’s negative of the elbow and wrist. Reflexes are +1 biceps, triceps and brachialis.

Thoracolumbar spine: She has some tenderness over the left trochanter, no localized tenderness over the back or SI joint with forward flexion 90 degrees and negative straight leg raise at 90 in the sitting and 70 in the lying position. She has a negative Trendelenburg test. She has a negative Stinchfield bilaterally. Patellar and Achilles reflexes +1 bilaterally with 5/5 strength in all muscle groups. Her lower extremity sensation is intact. Gait is normal. She is able to heel and toe walk without difficulty and is able to squat without difficulty.

Diagnostic Imaging:

Numerous diagnostic studies were provided for my personal review. These include the following:

09/18/2012 – X-ray right elbow, negative.

04/26/2018 – MRI cervical spine: Small herniated disc at C3-4, C5-6. No cord compression.

04/26/2018 – MRI of the lumbar spine: Disc desiccation, L5-S1 with small herniations at L3-4, L4-5 and L5-S1 with facet disease.

08/06/2018 – MRI of the right knee showing significant degenerative changes in the patellofemoral, medial and lateral compartments, as well as a lateral meniscus tear.

01/02/2020 – X-rays of both knees shows significant lateral compartment DJD bilaterally.

07/16/2020 – X-rays of both knees show significant lateral patellofemoral compartment arthritis.

01/06/2021 – MRI of the left knee shows an effusion with tricompartmental DJD. No meniscal tear.

08/09/2023 – MRI of the cervical spine shows C3-4, C4-5 and C5-6 disc protrusions with no foraminal compression.

08/09/2023 – MRI of the lumbar spine shows disc desiccation, L5-S1, with small herniations at L3-4, L4-5 and L5-S1 with no significant compression.

Medical Record Review:

Extensive medical records were provided for my review.

Answers to Interrogatories, Deposition Transcripts of [Redacted], [Redacted], the claimant, Vincent Jarrett, DO, a radiologist, Larry Rosenberg, MD, orthopedic surgeon, Robert Labaczewski, DO, a general practitioner who specializes in occupational medicine.

06/21/2023 – Accident report, photographs of vehicle showing damage to multiple vehicles.

Additional Answers to Interrogatories.

03/14/2005 – X-ray of the lumbar spine and pelvis. No significant disc space narrowing noted.

06/15/2005 – X-ray of the right knee, negative.

08/25/2007 – X-ray of the lumbar spine, no fracture.

08/25/2007 – X-ray of the cervical spine, no fracture.

09/18/2012 – Three views of the right elbow, no fracture.

04/26/2018 – MRI of the cervical spine done for radiculopathy: C3-4 annular bulge with shallow central protrusion and herniation, effacing the thecal sac. C5-6 annular bulge, effacing the thecal sac. Remaining disc spaces are unremarkable.

04/26/2018 – MRI of the lumbar spine: L3-4, L4-5 and L5-S1 bulging of the annulus, facet ligamentous hypertrophy and mild narrowing of the central canal. L3-4 and L5-S1 mild disc desiccations.

06/04/2018 – EMG nerve conduction studies: Acute and chronic S1 radiculopathy, right greater than left. Chronic L5 radiculopathy.

08/06/2018 – MRI right knee: Mild to moderate arthritic changes. Small effusion. Grade 2 intrasubstance tear involving the menisci.

01/06/2021 – MRI left knee: Osteoarthritic changes, most prominent patellofemoral and medial. Grade 2 intrasubstance meniscal tear, horizontal peripheral tear of an anterior horn of lateral meniscus. No medial meniscus tear visualized.

04/21/2022 – X-ray of right shoulder: Degenerative changes in the AC joint.

12/08/2022 – Photographs of some lumbar injections being performed.

06/21/2023 – CT scan of the cervical spine, Jefferson Emergency Room: No acute findings.

06/21/2023 – X-ray of the right hand: Unremarkable.

06/21/2023 – X-ray of the pelvis and right hip: Unremarkable.

06/21/2023 – Lumbosacral spine x-ray: Moderate facet disease seen. Straightening of normal lordosis. No acute fracture.

06/21/2023 – Right shoulder x-ray: No acute findings.

06/21/2023 – X-ray right wrist: No acute findings.

08/09/2023 – MRI cervical spine: Multilevel disc desiccation, C3-4 bulging in the annulus effacing the cord with mild to moderate narrowing of the central canal and mild left foraminal narrowing. C4-5 bulging of the annulus with mild narrowing of the central canal and left foramen. C5-6 bulging of the annulus with left paracentral protruding herniation effacing the cord. Mild narrowing of the central canal and left foramen.

08/09/2023 – MRI lumbar spine: T9-10, T10-11 disc desiccation with bulging annulus. L4-5 disc desiccation and bulging of the annulus, mild to moderate stenosis, left foraminal narrowing. L4-5 bulging of the annulus with moderate central stenosis and mild foraminal narrowing bilaterally. L5-S1 disc desiccation with bulging of the annulus with shallow central anterior disc herniation abutting the thecal sac and S1 nerve roots. Mild to moderate central stenosis.

09/27/2023 – EMG nerve conduction studies: Proximal nerve lesion on the right and left side at the L5 level.

11/24/2003 – Records from JFK Medical Center Emergency Room Visit.

08/25/2007 – ER records indicate the claimant was seen at JFK Medical Center, status post MVA of neck, back and abdominal pain.

08/17/2012 – Patient seen with chief complaints of low back pain radiating into the left leg.

04/10/2014 – Seen in the emergency department for non-orthopedic issues.

03/10/2018 – Records including a CT scan of the cervical spine, unremarkable.

03/10/2018 – Musculoskeletal exam done at Virtual Emergency Room, positive for back and neck pain.

03/13/2018 through 01/07/2019 – Records from Robert Labaczewski, DO. Numerous visits. Complaints of neck and mid and low back pain radiating to the extremities. Diagnosis of posttraumatic cephalgia, cervical strain/sprain, radiculitis, posttraumatic thoracic strain/sprain, posttraumatic lumbar strain/sprain with radiculitis. Musculoligamentous sprain of the right knee. Exam revealed diminished sensation noted over the lower extremities along the L5-S1 distribution. Recommendation is made for pain management.

01/02/2020 – Rothman Orthopedic Urgent Care – Patient seen for right knee pain, one month, and worsening. Ambulating with a slow antalgic gait. Examination of the right lower extremity reveals no gross deformity or ecchymosis. Tender over the MCL and MPFL. X-rays show unilateral osteoarthritis, right knee. Patient ultimately diagnosed with bilateral osteoarthritis of the knees. Cortisone injections recommended. Subsequent office visits noted Orthovisc injections.

11/18/2020 – Records from Jefferson Health. Seen for joint pain, left foot pain, osteoarthritis.

03/23/2021 – Records from Dr. Adam Goldstein – Seen for recurrence of sebaceous cyst in the posterior right shoulder x three weeks. Impression is cutaneous abscess of right shoulder.

09/14/2022 – Notes from Lindsay Hummell, PAC, Jefferson Health. Patient seen with diagnosis of cervical and lumbar radiculopathy. History of lumbar spondylosis, OA and joint pain. Pain has gotten worse over the ongoing years, getting numbness in the feet, with numbness for a few years now, gotten worse in the past month. The pain is everywhere, low back, bilateral knees, all the joints. Numbness and tingling in the upper and lower extremities bilaterally.

09/30/2022 – Records from Relievus, initial assessment. Patient complaining of neck pain, average 8/10, increasing over the past several months, radiating to both shoulders and shoulder blades. Complains of numbness and tingling in the upper extremities bilaterally, occurring throughout the day. Low back pain, 8/10. Neck pain began four weeks ago, increased several months ago. Patient is complaining of numbness and tingling with shooting pain in both lower extremities. Has tried physical therapy. The 04/26/2018 diagnostic studies of the cervical spine and lumbar spine were reviewed. Assessment: Cervical facet syndrome, disc herniation, C3-4, disc bulging C5-6, clinical cervical radiculopathy. Lumbar facet syndrome, disc bulging, L3-4, L4-5, L5-S1, clinical lumbar radiculopathy. Recommendation was made for a left transforaminal epidural injection L5 and S1. Possible future facet injection.

03/17/2023 – Ongoing treatment records from Relievus, Dr. Manabat. Office visit was for a cervical epidural injection for neck pain, cervical radiculopathy, C6-7.

06/30/2023 – Next visit, after the injury in question. States the patient was involved in an MVA where she hit another vehicle head-on, taken to the emergency room complaining of neck pain 7/10 radiating into both shoulders, stiffness, pain in the thoracic spine, pain in the lumbar spine, radiating into both buttocks. Diagnosis cervicalgia, low back pain, chiropractic trial recommended.

11/17/2025 –The claimant was most recently seen at Relievus on this date.

Ongoing treatment records through 07/19/2024 – Transforaminal lumbar epidural injection, left L5 was performed.

09/26/2023 – Records from Eastern Neurodiagnostic Associates describe the accident in question. Clinical impression: Postconcussive syndrome, posttraumatic chronic migraines, right hand pain, cervical myofascial pain with radicular features, lumbar myofascial pain with radicular features.

09/18/2020 – Independent Medical Evaluation (IME) performed by Dr. Larry Rosenberg. No objective evidence of impairment.

12/07/2020 – IME by Dr. Thomas Obade which appears to be a narrative report referable to the 03/10/2018 accident, opines chronic cervical strain, chronic lumbar strain, bulging discs, lumbar nerve root compression, traumatic chondral defect, left patellofemoral compartment. All these diagnoses are opined to be permanent.

Physical Therapy records from Washington Medical and Relievus as well as Health First Chiropractic Care were reviewed.

Impression:

On the basis of extensive medical records and review of diagnostic studies, I will make the following comments:

There are subjective complaints of pain in the neck and back with radiation into the arms and legs following the accident. These symptoms appear to be identical to symptoms that were being treated in the timeframe immediately prior to the accident in question. Having reviewed the diagnostic studies, there is no evidence of any significant material change in the claimant’s condition from before and after the 06/21/2023 accident. To the degree that she may have sustained a strain of the cervical spine, lumbar strain, or right wrist, it is possible that brief course of chiropractic care and/or physical therapy may have been appropriate. Independent of causality, she has no objective evidence of ongoing lumbar or cervical radiculitis at the present time. Having reviewed the records and diagnostic studies, I believe as it pertains to the 06/21/2023 motor vehicle accident, she has made a full and complete recovery and does not require any additional orthopedic care, nor does she have any objective evidence of residual impairment or permanent injury. Based on the physical examination today, which is objectively normal, she is capable of performing daily living activities.

All of the above opinions are given within a reasonable degree of medical certainty. Please feel free to contact me with any questions regarding this matter.

Sincerely yours,
John P. Nolan, Jr., M.D.