4 min read
Dr. Ponton Answers a Claims Adjuster's Questions
In this Q&A, Dr. Ponton answers questions from a claims adjuster about evaluating work-related injuries. Drawing on 15 years of active-duty experience caring for service members in physically demanding roles, he explains how his military background informs his approach to assessing workplace injuries. Dr. Ponton also discusses key factors that influence recovery and return-to-work timelines, including psychosocial elements and patient expectations, and shares his methods for identifying discrepancies between reported pain and actual functional ability when diagnostic studies are normal.
Ryan Ponton, M.D., FAAOS
Orthopedic / Hand Surgeon
Question:
How has your experience as a Navy flight surgeon shaped your approach to evaluating injured workers, and what aspects of your background have been most important in effectively assessing work-related injuries?
Answer:
As a Navy flight surgeon, my most important responsibility was determining which pilots were medically fit to fly. This required understanding both the physical demands of their job and the mental health of each pilot. To understand this, I routinely flew with the pilots, mostly as a passenger, and also learned about their lives outside of work, including family and hobbies.
Spending 15 years on active duty overall has been one of the most important factors for determining work-related injuries, as caring for service members with a wide variety of physically demanding jobs provided a large breadth of knowledge for evaluating occupational injuries and disease.
Question:
Based on your experience, what factors do you believe have the greatest impact on recovery and return-to-work timelines for claimants with severe tendon injuries, such as a complete tear or rupture?
Answer:
In my experience, psychosocial factors have the greatest impact on recovery and return-to-work timelines for claimants with severe tendon injuries. There is a growing body of literature across all orthopedic subspecialties that psychosocial factors (support network, job satisfaction, mental health) have the greatest impact on self-perceived disability and musculoskeletal function. Both as a treating surgeon for workers' compensation injuries and as an IME physician, you have a reasonable idea of how well a claimant will do prior to an intervention.
Another notable factor is claimant expectation for their recovery and return-to-work timelines. For instance, when I am the treating surgeon for a distal biceps rupture, I mention at the first appointment that the recovery is 4-6 months after surgery. At each subsequent appointment, I try to mention that timeline again. If a claimant is informed early and often about the expected time course, they tend to do better. It is much more difficult to manage claimant expectations from a single encounter IME.
Question:
What is your approach when a claimant reports significant pain or limitations that they feel prevent them from working, but the diagnostics show no acute injury? Are there any tests you perform to identify discrepancies between the worker’s reported limitations and their actual functional abilities?
Answer:
Accurately diagnosing orthopedic conditions is based on the history, physical exam, and diagnostics. If diagnostics are normal, I focus more on the history and physical exam. It is quite unusual to have 0% improvement, or even worsening, from the time of injury to the IME appointment for the majority of work-related conditions. Additionally, the larger the distribution of symptoms present in a particular body region, the less likely there is an organic etiology for the pain.
When assessing strength during an exam, give-way weakness is an easily identifiable sign of functional overlay. When testing range of motion and strength, I try to move rapidly back and forth between the affected and unaffected side. I will also go back and retest certain muscles groups later in the exam. If there is functional overlay, claimants are unable to reproduce consistent findings. The grip dynamometer is a very useful tool. If I suspect a lack of effort for grip strength measurements, I will examine grip strength through all five stations on the dynamometer. It should produce a bell-shaped curve. If the claimant records the same grip strength across all five stations, this indicates a non-anatomic, non-physiologic finding.
Ryan Ponton, M.D., FAAOS, is a board‑certified orthopedic surgeon specializing in hand and upper extremity surgery. He provides expert surgical care for conditions such as carpal and cubital tunnel syndrome, hand and wrist arthritis, nerve injuries, and tendon and ligament injuries. Dr. Ponton earned his medical degree from the Uniformed Services University of the Health Sciences and completed his orthopedic surgery residency at the Naval Medical Center San Diego, where he also served as Associate Master Clinician and Assistant Professor of Surgery.
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A Previous "Ask the Doctor" Response
In our previous "Ask the Doctor" blog, Dr. Eng discusses how she evaluates PTSD and other mental conditions within a workers' compensation setting.