To whom It may concern,

The claimant was seen for the purposes of an Independent Medical Examination today, 3/4/25, in relation to alleged injuries from date of incident on 11/29/21. Prior to the exam, the nature of the evaluation and the fact that no doctor/patient relationship exists was explained.

History of Present Illness:

The claimant states that on 11/29/21, he was driving behind a truck when he was involved in a chain reaction MVA and sustained multiple injuries. He stated a truck in front of him was going slowly and a car in front of him stopped, when a second car hit him and flew on top and hit the roof of his car. He injured his right knee, right ankle, low back, neck, both shoulders, left elbow and right elbow. He states he was admitted to a hospital, staying overnight. X-rays and scans were taken. He had some kind of injection into his belly and was discharged. He states over time he was treated by pain management where he had therapy, and he was referred by his attorney to a pain management doctor. He also states he had a concussion, and that he was treated for that as well during this time period. He said treatment included physical therapy, pain management shots in both shoulders and forearm on the left. He states he never had any surgery associated with the accident. He said that he was evaluated by a shoulder surgeon over time and got shots in his shoulders. He states that his neck and low back had shots, and he had nerve ablations on 2/26/25.

He states he had no prior injury to these body parts or subsequent injuries although he later reported right shoulder surgery years ago.

Concerning his symptoms, he states his shoulders are the same and no better. His elbows are the same, no better. His right ankle is fine. His right knee is better, his neck is worse, and his low back is worse.

Past Medical History:

Past medical history reveals that he has allergies to Tamiflu and Levaquin. He has multiple medical problems including depression, increased cholesterol, surgery for deviated septum, and he had a scope on the right shoulder years ago and states he got better, and he had adenoid surgery.

Social History:

He does not smoke. He occasionally drinks some beer. He is a warehouse coordinator and a relief driver and states he is not working.

Medications:

He’s on multiple medications including Wellbutrin, gabapentin, cholesterol medicine, Advil and Tylenol.

Diagnostic Studies:

To note, there was no imaging available for my review today.

Medical Record Review:

Review of medical records is extensive, as there are about 1,500 pages to review.

I reviewed a set of legal documents provided to me.

I reviewed diagnostic studies, reports only, no imaging. There were multiple studies during his admission at Grandview Hospital all dated 11/29/21, to and including 11/30/21.

CT of the cervical spine dated 11/29/21, which revealed degenerative disc disease of C5-6 with multilevel spondylosis and cervical reversal.

There x-ray report, dated 11/29/21, which is a right fibula x-ray, which was negative.

There is a right elbow series, dated 11/29/21, which was negative with no abnormality.

Chest x-ray dated 11/29/21 was read as normal.

CT of the brain dated 11/29/21, which is reported as negative with no abnormal findings.

CT of the abdomen and chest dated 11/29/21, which showed a fatty liver and a cystic liver. There is a lesion in the liver with 2 cm mass, an accessory splenic nodule with no evidence of any bony injuries described in the report.

On 11/29/21, he had a pelvis x-ray series, which was negative, no fractures noted.

On 11/30/21, he had 4 views of his right knee, which is described as normal or negative.

On 11/30/21, he had two views of his right foot, which were negative for fracture and dislocation, but he had a bipartite sesamoid.

Then there was the imaging report of his MRI of his right knee, dated 3/2/22, revealing some mild soft tissue edema and a small effusion, otherwise no fractures, no dislocations, no ligamentous injuries or menisci tear described.

An MRI of lumbar spine dated 3/11/22, revealed degenerative disc disease, at L5-S1 a tiny bulge with multiple dehydrated discs.

MRI of his left elbow dated 3/11/22, which is consistent with a tendinosis vs. strain of his left medial elbow tendon.

He had an MRI of the left shoulder on 4/6/22, which showed a mild tendinitis of the rotator cuff and the biceps tendon, arthritis of the AC joint, but there was no fracture, dislocation or rotator cuff tear.

MR of the cervical spine dated 10/10/23, which described multiple bulging discs from C3 to T1 with facet disease, central foraminal narrowing, from C5 to C7 to and including disc bulging and central foraminal narrowing at T1 and T4.

There was also an EMG and nerve conduction study, which revealed a suggestion of a C5 radiculopathy by a Regen Doctors.

I then had the opportunity to view multiple physician notes. One was a family medicine series visit 3/29/21 which appeared to be some type of telehealth visit.

I had an opportunity to review Grand View Hospital admission notes of 11/29/21. The description described he was an MVA driver, self-extracted with low back pain, cervicalgia, right ankle and foot pain, right elbow pain, left knee and right knee pain. His chief complaints at the time of his admission was right ankle pain, low back pain in both shoulders. He was admitted for observation, and had multiple x-rays as noted above in the imaging section. Their impression at that time was MVA crash. There were trauma notes which evaluated his neck and his back. CT of his neck was apparently read as negative. On the examination of his neck, they described a normal exam during his admission, and they felt he was safe for discharge. They also evaluated his back, right ankle, knee and foot, and thought he was okay for discharge. There was no evidence of any fracture or dislocations.

He was then seen on 12/1/21 by family medicine. They reviewed his history of injury and mechanism of injury. His chief complaints were jaw pain, left ear pain, neck pain, shoulder pain and stiffness. His diagnosis at that time of that evaluation was neck pain, low back pain without sciatica, multiple joint pain and hepatic hemangioma. During that evaluation they reviewed the x-rays and CT scan reports from the hospital and recommendations for Celebrex, cyclobenzaprine and PT.

He was then seen by Regen Doctors dated 12/3/21, where the recommendation of that visit was consistent with PENS treatment. They reviewed his chief complaints of head and neck pain, upper, mid-back, bilateral leg pain, right knee pain and ear pain. The diagnoses at that time were sprain of the lumbar spine, lumbago with sciatica, sprain of the cervical spine. The recommendation at that time was a Medrol Dosepak and PENS therapy.

There was a 12/7/21 telehealth visit which there was no diagnosis or treatment noted.

He was then evaluated by Orthopedic Foot, Ankle, & Knee Institute on 12/8/21, where he was evaluated for his right knee, low back, leg pain, right ankle pain. They described his MVA and his accident as the mechanism injury. They completed a history and physical examination. He was taking NSAIDs and Flexeril. They also had the opportunity to review his x-rays which revealed, in their opinion, DJD in the right knee medial compartment and the right ankle x-ray revealed DJD. His diagnosis was right knee synovitis with effusion, strain, internal derangement and cervicalgia, strain of mid-back. At the time of that evaluation, they recommended MRI for the ankle and the knee. PT was also prescribed and also recommended an MRI of his foot.

Then he was seen in 12/9/21 at Good Shepherd Physical Therapy, and he was also evaluated on 12/10/21 for concussion symptoms. This was by Kyle Klitsch, who was a physician. He then continued to be evaluated on 12/22/21, again for his Good Shepherd evaluation, which appeared to be associated with concussion symptoms.

He was then seen on 1/4/22 by Regen Doctors where they described head, neck, upper back, mid back, low back, bilateral leg pain, right knee pain, left ear pain, and PENS treatment was accomplished. He was then seen in 1/7/22 and 1/21/22 by Regen Doctors and PENS treatments were noted.

He then was evaluated on 1/24/22 by CC LVPG Ortho for right knee pain. They reviewed x-rays. They suggested NSAIDs and an MRI. There is also an evaluation by Regen Doctors where no treatment was noted on 2/11/22.

He was then seen by Dr. Klitsch and on 2/22/22 with assessment of headache; concussion injury of brain; multiple injuries; new patient visit; concussion; S/P major multi trauma.

On 3/7/22 he was seen by Gabriel E Lewullis, MD for an ortho follow-up for his right knee with an MRI where they noted his pain was improved. They felt he had patellofemoral syndrome and sent him to PT.

He continued to be followed up on 3/25/22 by Regen Doctors. The treatment was the same. They reviewed a history and physical examination and underwent injections of his medial epicondyle on the right.

On 4/5/22, again it is noted that he underwent concussion therapy by Dr. Klitsch.

On 4/27/22, he was seen by Regen Doctors, and no change was noted in his treatment other than continued PT.

On 5/18/22, he then received concussion therapy.

On 5/25/22, after seeing Regen Doctors, history and physical examination was completed. He received an injection to his left elbow over the medial epicondyle.

He was then seen on 6/21/22 by Regen Doctors where a history and physical examination was completed. They recommended based on his multiple diagnosis that he have an EMG, ortho evaluation for his left shoulder, continue concussion care, and follow up in 4 months.

I reviewed a procedure note, dated 11/2/23, where he underwent a C4-5, C6-7 medial branch blocks on the right. On the left, he underwent C4-5 and C5-6 facet blocks.

He then had multiple visits in therapy and chiropractic care from 12/6/21 to and including 6/13/22.

Multiple billing notes from 11/29/21 to and including 12/14/23.

Lab reports of 11/29/21 x2.

On 8/13/24 he was seen for an Independent Medical Evaluation by Sr. Sexton who opined he sustained. His assessment was aggravation of cervical degenerative disc disease with persistent right upper extremity radiculopathy, aggravation of right shoulder condition with ongoing internal derangement, right upper extremity injury with cubital tunnel syndrome, aggravation of lumbar degenerative disc disease with disc protrusion at L5-S1 and right lower extremity radiculopathy, right knee contusion with patellofemoral pain syndrome, multiple abrasions and cuts to the right lower extremity, and left shoulder internal derangement with findings compatible with impingement syndrome and biceps irritation.

Dr. Levenstein of Regen Doctors issued a narrative report dated 2/28/25 which detailed the treatment he provided in relation to the 11/29/21 MVA and recommended further treatment.

Physical Examination:

Exam revealed a 52-year-old male, right hand dominant.

His neck exam revealed an active and passive range of motion which was full today with normal endpoints. He touched his chin to his chest and his chin to his right and left shoulder without difficulty. He had no spasm. Range of motion of both shoulders actively and passively were full at normal end points. His impingement, drop arm and Hawkins’ tests were negative bilaterally, but he had some discomfort on extremes of motion. He had no sensory or motor deficits noted in either upper extremity. This is noted in all muscle groups and dermatomes. His biceps, triceps, and brachialis reflexes were normal bilaterally. Range of motion of both elbows measured by goniometer were 0 to 130°, equal and symmetrical. Pronation and supination were full, equal and symmetrical. He was mildly tender in his medial epicondyle on the left. He had no pain in forced stretching or forced flexion of both elbows. He had no tenderness in his lateral condyle as noted. His thoracic spine was non-tender, no spasm. He had minimal tenderness about his lumbar spine. He could flex his waist at essentially about 90°, extend to 0°. He could rotate right to left to 40° without difficulty. He had painless range of motion of both hips actively and passively. There was no pain or tenderness over his trochanteric bursae or SI joints, or sciatica notches bilaterally. He had no sensory or motor deficits noted in either lower extremity in all muscle groups and dermatomes.

His right knee had an active and passive range of motion. It was measured from 0 to 140°. He had minimal tenderness about his knee on palpation and he had no pain on apprehension and inhibition tests. He had no ligamentous laxity of the right knee including ACL, PCL, MCL and LCL. There was no knee effusion. There was no crepitus.

His left knee exam had a range of motion symmetrical to the right knee, 0 to 140°, measured by a goniometer. He had no ligamentous laxity, no effusion of either knee or no crepitus. His ACL, PCL, MCL, and LCL testing normally.

On right ankle exam, revealed and active and passive range of motion which is full and symmetrical to the other side and was non-tender. He had no swelling of either leg or ankle. His gait and station were normal. He could stand and rise from the examining table without difficulty.

His patella and Achilles reflexes were normally bilaterally +2/4. His biceps, triceps, and brachialis reflexes were normal at +2/4, bilaterally.

Impression:

Concerning the cervical spine, this was a sprain/strain of the cervical spine with exacerbation of pre-existing condition of cervical spondylosis that has resolved. He is now dealing with apparent age-related symptoms of his neck.

Concerning the diagnosis of his shoulders, he had a strain/sprain of both shoulders with a tendinosis of his biceps, rotator cuff tendon and AC joint arthritis of his left shoulder which has resolved. Concerning his right shoulder, I believe he had a strain/sprain of his right shoulder, which also appears to have resolved.

Concerning his elbows, he had medial epicondylitis, post-traumatic bilaterally. He has residual tendinosis of the medial epicondyle which is chronic now.

Concerning his right knee, I believe he had a contusion or a sprain/sprain of his knee, which is resolved. There is no evidence of any objective mechanical injury to his right knee at this time based on his MRI findings and his physical examination.

Concerning his right ankle, he had a sprain of his ankle which is resolved.

Concerning the lumbar spine, he has a strain/sprain with exacerbation of previous existing condition of DJD and DDD of the lumbar spine and is now dealing with age related symptoms.

It is my opinion at this time that his treatment was indicated and the standard of care for his injuries as noted for the 11/29/2021 MVA. No further treatment is necessary for those injuries. I do not find that any of the injuries sustained at the time of the MVA are permanent in nature and furthermore it is my opinion that the claimant can perform all activities in an unrestricted manner at this time.

All of the above opinions are given within a reasonable degree of medical certainty.

Sincerely yours,
David Eingorn, M.D.