To whom It may concern,

The claimant was evaluated in my office on 11/14/24, for the purpose of an Independent Medical Examination. The claimant was informed that the examination was for evaluative purposes only; intended to address specific injuries or conditions as outlined by you. This is not intended as a physician/patient relationship. The claimant was asked at the time of the examination not to engage in any physical movements beyond personal limits, which may be painful or those which could cause harm or injury.
The claimant presented to the office with photo ID. She was accompanied by others.

History:

The claimant is a 49-year-old, right hand dominant contract administrator. She was involved in a motor vehicle accident on or about 1/1/22. At that point, she was the driver, seat belted, when she was struck on the driver’s side toward the front. By report, the front of the vehicle was demolished and airbags deployed. She needed to be extracted by the fire company. She thinks she might have hit her left knee on the dash. The claimant was taken to St. Mary Medical Center where she had fractured teeth which were treated with resin. She was complaining of left knee pain and left ankle pain, had a concussion, and was also complaining of left neck pain which was radiating down into her left arm. She was seen and evaluated at St. Mary Medical Center where she, by report, had no fractures. She followed up several days later with Dr. Scott, who is an internal medicine physician and specializes in motor vehicle accidents. He referred her to Dr. Ford, a chiropractor, and she underwent chiropractic care for at least six months for her neck and her arm. She also saw Dr. Steven Gecha from Princeton Orthopedics. She had known Dr. Gecha before, as he performed surgery on her in 2021 for arthritis in her left knee, the same side. At that point, he had done a lateral release and a cleanup. When she saw Dr. Gecha and was evaluated, he gave her an injection of steroid and lidocaine and placed her in three months of formal physical therapy. She states therapy helped. He did not order any additional advanced imaging.

She was then evaluated by Dr. Shah, a neurosurgeon. We do not have those records but, according to the claimant, he had recommended some type of surgical spine procedure, I believe a fusion procedure. The claimant had declined and is now seeing Dr. Perlman for pain management. She has been seeing him for pain management for her neck for the last three years. She states that every three months or so, he injects her with epidural injections which give her about three months of relief.

Currently, there is no one who is treating her knee. She is currently not interested in any type of surgical intervention. She does state she had an MRI of her cervical spine. She reports that her left ankle pain is completely resolved.

Today, the claimant states her cervical spine baseline is 3/10. She says all of her left arm pain has resolved. She only has neck pain with localized neck numbness in the midline. She has no radicular complaints. She does report that she feels weakness with grip and pinch and lifting overhead on the left side. She is using Lidoderm patches and heat on a regular basis and, when necessary, she takes Celebrex and Tramadol. She reports she takes Celebrex approximately three times a week.

Functionally, she is able to do activities of daily living, but she does have trouble with her hair and driving. She has trouble turning her head. She works as a contract administrator and is working regular duty with no restrictions. She states her left knee pain is better, but she has had one or two episodes of giving way. She says her largest complaint of pain is when she goes from a seated position to standing. She reports the last time it gave way was about a month or so ago when she was going up the steps. She had to grab onto the railing, and she did not fall. Her baseline left knee pain is mild at a 2/10. It gets worse if it gives way and that could be a 6. She has no other mechanical symptoms of effusion, catching, or locking. She denies numbness, tingling, or pins and needles in all 4 extremities. She states functionally she can’t run, and her biggest concern is about carrying if she ever had grandchildren in the future.

Past Medical History:

Her past medical history is significant for hypertension.

Past Surgical History:

Past surgical history is significant for left knee lateral release and a clean out in April of 2021. This was prior to her accident. She does not know why she had arthritis in her knee and whether they did anything else structurally.

The claimant is allergic to surgical lube.

Social History:

She lives with family. She works as a contract administrator with no problems. She can do essentially all of her activities of daily living except for having trouble with her hair and driving.

She does not smoke or drink.

Physical Examination:

The claimant walks with a heel-toe tandem gait. She can walk on her heels and toes. She easily gets onto the chair and gets on the exam table with no difficulty. There is no obvious distress. Cervical spine flexes to 60°, extends 60° and rotates and lateral bends 60°. She has no localized tenderness and no spasm. She has negative Spurling’s maneuver and a negative Lhermitte’s sign. Bilateral upper extremity, including shoulder, elbow, and wrist all have full range of motion. Her upper extremities neurologically reveal that her deltoid and rotator cuff strength are 5/5. Biceps and triceps are 5/5. Wrist flexion, extension, finger flexion, extension and abduction are 5/5. Sensation is intact from C4 to T1, and she has no sensory deficits.

Left knee examination reveals a well-healed lateral portal scar. She has full extension and flexion to 135°. She has no effusion. She has mild crepitus with range of motion. She has no ligamentous laxity. She has mild tenderness along the medial joint line. She has negative McMurray’s, negative Lachman’s, negative pivot shift, and negative posterior drawer.

Diagnostic Studies Reviewed:

MRI left knee from Mercer Diagnostic Imaging dated 3/18/22, which revealed tricompartmental osteoarthritis, worst in the patellofemoral compartment with near bone-on-bone changes laterally, complex tearing of the posterior horn and body of the medial meniscus extending to the inferior articular surface with associated parameniscal cyst formation, small joint effusion, and strain/tear of semimembranosus muscle with joint space effusion.

MRI left knee from Princeton Radiology dated 10/2/20, which was read as a probable peripheral medial meniscal root tear with reactive changes in the tibia, Grade 3 patella changes, and mild spurring off the medial and lateral femoral condyles.

CT scan of the head and neck dated 1/1/22 from St. Mary Medical Center, which reveals no bleed in the head, no acute fracture. The cervical spine was noted at C4-C5 and C5-C6 to have degenerative disc disease.

X-ray of the left knee dated 1/1/22, which is the day of the motor vehicle. The left knee x-ray impression was mild medial degenerative disc disease. The left ankle x-ray was negative.

MRI of the cervical spine from Mercer Diagnostic Imaging dated 3/18/22. The impression is a broad-based posterior and left paracentral disc herniation at C5-C6 with inferior migration causing mild narrowing of the central canal and moderate narrowing of the neural foramina bilaterally. The disc herniation measures 7 mm in size. Mild facet arthropathy is seen. Diffuse protrusion of C4-C5 disc causing mild narrowing of the central canal and neural foramina bilaterally. Protrusion measures 3 mm, mild facet arthropathy is seen. Diffuse bulging at C6-C7 without significant central or foraminal narrowing. The bulge measures 2 mm with mild facet arthropathy. Diffuse bulging at C3-C4 disc without any significant central canal or neural foraminal narrowing. The bulge measures 2 mm. Subtle, altered marrow signal intensity involving the posterior arch elements of C4 and C5 vertebrae on the right, and they thought this possibly could be degenerative or traumatic. There is also a mild C4 and C5 anterolisthesis. And lastly, there is mild retrolisthesis at C5 and C6.

Notes From Physicians:

Patients saw Dr. Stier in 2012 for left knee pain for which she was treated with PT and injection.

Note from Dr. Risi dated 8/19/20, where the patient was complaining of neck and right shoulder pain treated conservatively.

Note from Dr. Culp from Princeton Orthopedics dated 9/25/20, where the patient was again complaining of left knee pain. She was treated with injection therapy. An MRI was ordered, and she saw Dr. Gecha. The MRI revealed patellar chondrosis with a question of a medial meniscal tear.

Notes dated 11/4/20, where the patient had three injections, three weeks apart with Viscosupplementation.
Follow up from Princeton Orthopedics dated 1/20/21, where the patient was diagnosed with progressive patellofemoral arthritis and pain, which was treated with injection therapy.

OR note from Dr. Gecha dated 4/6/21. His impression was tricompartmental arthritis, medial meniscal tear, and chondromalacia of the patella with excessive lateral pressure syndrome. The body of that note reveals that the patient had Grade 3 arthritic changes from 0 to 100 degrees of the medial femoral condyle, Grade 3 changes in the medial tibial plateau, Grade 3 changes from 20 to 40 degrees with a 2 cm diameter of the lateral femoral condyle, entire lateral facet and half for the inferior half of the medial facet had Grade 3 arthritic changes, and the trochlear groove had Grade 3 arthritic changes.

Note from Dr. Tyrrell, dated 11/12/21, revealing neck pain, treated non-operatively.

Note from Dr. Perlman dated 12/29/21 before the accident where the patient had a left suprascapular nerve block.

Note from the emergency room dated 1/1/22, where the patient stated that she self-extricated herself from the car. This is a different story than she gave me.

Of note, the patient has a history of gout, which she is taking allopurinol and occasionally colchicine for flare-ups. When mentioned or asked if the patient had any medical problems, she stated she only had hypertension.

Impression:

Left knee contusion.

Cervical strain.

Causality:

The claimant’s left knee arthritis and the claimant’s previous medial meniscal tear are not causally related to the motor vehicle accident in question. The claimant’s left knee contusion was causally related. The claimant’s current complaint of left knee pain is most likely the natural progression of her underlying arthritic knee. I cannot rule out that she had a partial exacerbation from the motor vehicle accident. The claimant’s cervical strain was causally related. The claimant’s multiple disc bulges from C3 to C7 were not causally related nor was the facet arthropathy. Those were pre-existing in nature. It is possible the claimant did have a material exacerbation or that this is also the natural progression of her underlying degenerative spine.

The claimant, at this point, needs no additional non-operative treatment, including physical therapy. Based on her history and physical, any additional surgery to her left knee would be related to her underlying previous arthritic knee changes that were noted on the surgery dated 4/6/21.

With reference to the claimant’s injections every three months from Dr. Perlman, and at this point, these are palliative in nature and not curative. At the current time, the claimant can work regular duty with no restrictions and does not have any type of physical disability based on the accident of 1/1/22.

Additionally, in reviewing her history and physical, she had essentially normal range of motion of her cervical spine with a normal upper extremity neurological examination and, therefore, most of her complaints were subjective in nature.

All of the above opinions were made within a reasonable degree of medical certainty.

The claimant left the office in the same condition for which she arrived and at no time were treatment recommendations given. The claimant’s history prior to going on with the physical was read and repeated to the claimant, and she concurred that there were no omissions or errors.

Please feel free to contact me with any questions.

Sincerely yours,
Frederic A. Kleinbart, M.D.