Medical 001

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GERALD ALLEN, M.D.

WAS CALLED, AND HAVING BEEN DULY SWORN, WAS EXAMINED AND TESTIFIED AS FOLLOWS:

MR.  STANTON: Today’s date is June 11, 1992. We are at the medical office of Dr. Gerald Allen in the matter of Debra Foster versus the State of Pennsylvania Liquor Control Board.  The Doctor’s deposition is being taken in lieu of the Doctor’s appearance at the time of the hearing.  All objections should be made on the record. Additionally, there is an agreement that the Doctor’s Curriculum Vitae be made part of the deposition in lieu of the Doctor’s recitation of the same.

DIRECT EXAMINATION ON QUALIFICATIONS

BY MR. STANTON:

Q. Doctor, this Curriculum Vitae accurately represents your various post‑graduate training, your certifications and your affiliations; is that correct?

A. That is correct.

MR. STANTON: Cross on credentials?

MR. COLLINS: I have no questions.

MR. STANTON: Very good.

DIRECT EXAMINATION BY MR. STANTON:

Q. Doctor, did there come a time when you examined one Debra Foster per the request of Attorney David Howard III?

A.  Yes.

Q. All right. When was that?

A. May 28, 1992.

Q. At that time, Doctor, did you take a history from her?

A.  Yes.

Q. What was the history?

A. She told me that she was 60 years old. She was previously employed by the Pennsylvania Liquor Control Board as a cashier at a liquor store for many years.  She had a past medical history of being involved in a work‑related injury approximately ten years ago when she fell at work cracking a bone in her low back. She told me several years ago she developed some sciatica with pain down both legs as well.  Treatment was given at that time and the pain resolved.

She was in a usual state of health at work which required her to use her right hand at the cashier stand at which she worked at and use her left hand to bag bottles and lift with both hands when she began noticing a significant amount of pain in the left hand and swelling around her thumb area. She saw some physicians for this problem. She saw three surgeons.

She was working up until October of 1991 when she eventually had to come off work due to persistent pain and unresponsiveness to conservative treatment. Two of the surgeons that she saw have recommended performing possible tendon transfers, and another recommended the possibility of a joint replacement at the thumb.

The records I reviewed include records from physicians, Dr. Morton, Dr. Jacobs, Dr. Stephens, Dr. Devlin, and Dr. Sellers.

Q. Doctor, what were her complaints when you saw her, which I believe was on May 28, 2992?

A. Yes. She told me that she subjectively had symptoms of trouble using her left hand, most specifically her left thumb. Any movement at all of the thumb made it difficult for her and caused pain.

She had trouble with activities of daily living, such as buttoning her shirt or coat because of the left thumb pain. She also had pain in the dorsal aspect of the thumb, not only in the base of the thumb.

She has no swelling around the thumb anymore, and she basically tried to rest the thumb as much as possible; but she was never without some discomfort with movement of that thumb.

Q. What about her lumbar spine, Doctor? What were her complaints?

A. She said it was relatively stable. She had no increase in back pain or leg pain. She told me that she was having some increase in back pain while performing her activities at work; but at the present time, she was able to walk around Lake Scranton three times a week and had done relatively well with her back and no specific problems. No history of numbness or tingling in her legs or back. No loss of bowel or bladder continence.

Q. Was there a past medical history of any significance, Doctor?

A. Yes, significant for dysfunctional uterine bleeding which she treated for at Geisinger. Hyperthyroidism and chronic anxiety neurosis. Hiatal hernia and bronchial asthma.

Q. Did you examine her, Doctor?

A.  Yes.

Q. Can you tell me what your examination entailed, and your findings?

A. Well‑developed, well‑nourished, 60‑year‑old white female. No acute distress. The examination was centered around her left thumb, initially; and she had significant diminished range of motion of the left thumb at the CDC joint. That’s the joint at the base of the thumb.  She had a positive Finkelstein’s test, which is a test for the tendons on the top of the thumb to see if they are inflamed at all. She had some discomfort when I asked her to perform that motion. Essentially, it is putting your thumb into the palm of your hand and putting your wrist in a downward motion.  She had tenderness over the 21 extensor tendons of the thumb on palpation.  There is no joint effusion or synovial hyperplasia. Neurological exam of the upper extremities was normal.  Range of motion of the patient’s lumbar spine was then tested. The patient had full forward flexion without complaints of pain. Lumbar extension produced some mild left‑sided low back pain and left hip pain.   While the patient was standing on her right leg and performed the lumbar extension motion, she had no back pain or leg pain.‘ While she was standing on her left leg and performing the extension, the patient had significant left‑sided back pain and left hip pain consistent with the previous complaints of back pain and leg pain that she had in her history.

Q. What was the neurological examination of the lower extremities?

A. Normal neurological examination.

Q. Did you do a straight leg raising test?

A.  Yes.

Q. And the results?

A.  Negative.

Q. What were you testing for there?

A. To see if there was any impingement of the nerve roots coming from her spine, disc herniation, such as that.

Q. Did you test the strength in her upper extremities?

A.  Yes.

Q. And the results?

A. She had some decreased strength in her left hand compared to the right. She had poor grip strength and poor fine motor coordination due to loss of motion of the thumb. She had reduced opposition, abduction, and extension of the thumb.

Q. Did you have any X‑ray films, Doctor?

A. No, I didn’t. I had X‑rays reports, but I didn’t have the actual films.

Q. What did the reports reveal?

A. The X‑ray dated 8/3/91 of the left hand showed degenerative changes in the first carpal metacarpal joint. X‑ray of the lumbar spine and left hip dated 10/21/91 showed evidence of a Grade II spondylolisthesis of L5 and S1 with degenerative changes at the hip region.

Q. What is your diagnosis, Doctor?

A. My first diagnosis was degenerative arthritis of the carpal metacarpal joint of the left thumb and chronic recurrent tendonitis of the left thumb.

Q. And regarding her low back?

A. Chronic low back pain secondary to the spondylolisthesis and degenerative disc disease.

Q. Doctor, did the patient give you or were you provided with any type of understanding or description of what kind of

pain consistent with the previous complaints of back pain and leg pain that she had in her history and the work she did?

A. What she told me.

Q. What was that?

A. She told me she worked as a cashier. She used her right hand to depress the keys on the cash register. She told me that she used her left hand, grasping bags to place bottles into the bags. She told me that she had to do lifting of cases of liquor for which she used both arms to do that.

Q. Doctor, based upon your understanding of her job and your examination of her, do you have an opinion within a reasonable degree of medical certainty as to whether or not the problem as you diagnosed it with her left thumb had any relationship to her work?

A. From the history that the patient told me and the repetitiveness of the activity, I would have an opinion, yes, that work could have aggravated that problem with her thumb.

Q. Doctor, do you have an opinion as to whether or not the condition of her thumb as you appreciated it based upon your examination would have been disabling to her to perform her job as you understand it?

A. I think the patient probably could have done things at work, even with the thumb if it was splinted, or possibly if she just kept away from using it a great deal. There are a lot of things that she can perform at work.

MR. COLLINS: Let me object and say that that is not responsive to the question asked, and it should be stricken.

BY MR. STANTON:

Q. Doctor, to rephrase the question, do you feel she could perform her work given the condition with her thumb, within a reasonable degree of medical certainty?

A.  Yes.

Q. And your opinion is?

A. That she could perform that.

Q. With regards to the condition of the lumbar spine, Doctor, do you feel that that condition had any relationship to her work or the activities of her work?

A. No, definitely not. 

Q. Why is that? 

A. Well, two reasons. No. 1, her physical examination was strongly suggestive of pain seen with spondylolisthesis which is a congenital problem.

Anybody that has pain in their back with extension of their spine, and if it is localized to one area and you ask the patient to stand on the same leg where the pain is being produced and go into extension and that makes the pain worse, that certainly is indicative of pain from spondylolisthesis.

It is evident in this case when the woman stood on her left leg and bent backwards she had significantly more pain.

Also she hasn’t been working for a while. I would have to say that certainly the fact that she hasn’t been working and she still has that amount of pain when you do a provocative test for spondylolisthesis, therefore, that pain that she consistently has is more based on that and not on any work related problems.

MR. STANTON: Thank you, Doctor.

CROSS‑EXAMINATION

BY MR. COLLINS:

Q. Doctor, so I have a clear idea, you described your understanding of what her job duties are; is that correct? That would be, in general terms, putting bottles into bags and also with both hands lifting cases of liquor.

A. Yes. That is part of her job duties; correct.

Q. Why don’t you tell me everything else that you took into consideration in your opinion?

A. Cashier work that she does. Well, she works at the register and collects the money and things of that nature at a register.

Q. In your report you indicated she was employable.

A.  Yes.

Q. You are now giving your opinion, as I understand it, that she can return to her former employment at the position and job duties that she was performing that you described?

A. Certainly, I would think, and I’m not employed at a liquor store obviously; but I would think that from what she told me, most of the job, as she explained to me, she can do.  Would she have problems lifting heavy cartons? Maybe. And instead of lifting one heavy box full of bottles, she can lift—she can take one bottle out at a time.

‘Q. Am I correct, Doctor, if she was required to lift heavy cartons and bottles of liquor, she would not be able to perform that job task?

MR. STANTON: Just interject an objection at this time as being not substantiated by the record, or that there will be offered testimony that that was not a part of the job duties she had to do; and a characterization also of heavy without a further delineation as to weights.

BY MR. COLLINS:

A. She may have trouble with it, yes.

Q. You’re indicating to me that she has the ability to perform certain job tasks?

A.  Yes.

Q. The question I am asking you is: Can she perform the job task, as you understand it in the position she held at the Liquor Control?

A. I would say most of them, yes.

Q. Not all of them?

A. She may have trouble with the heavy boxes if she was asked to lift heavy boxes.

Q. Let me ask you specifically if she is able to perform general housekeeping duties to keep the store bins and bottles clean? The sweeping, mopping, washing windows, cleaning bathrooms, involving bending and stooping?

A. Yes. That I believe she can do.

Q. Take stock inventory, which involves walking, bending and stooping?

A.  Yes.

Q. Arranging stock and replenishing supplies in bins involving lifting, bending, stooping, climbing bins or ladders?

A. Yes. Again with the thought that heavy boxes full of 5 ‑‑ whatever, 12, or however many bottles of liquor in one of those heavy boxes, she may have problems doing that.

Q. Assisting the customers with heavy or multiple purchase of merchandise. This involves carrying liquor averaging 40 to 50 pounds to customers’ cars or several packages of liquor.

A. She may have trouble with that.

Q. So you don’t know presently whether she has the ability to perform that?

A.  Right.

Q. Does she have the ability to stack cases of liquor? This involves lifting cases of liquor as high as six feet for a period of at least an hour.

A. Heavy cases of liquor, she may have problems with that.

MR. STANTON: Just note a continuing objection as to the accuracy of her particular job as opposed to the general  ‑‑

BY MR. COLLINS:

Q. Let me ask you to assume that the information that I am reading to you and asking your opinion on is as a result of documents being provided with reference to the description of the job duties of an individual member of the PA Liquor Control Board.

Specifically, again, unloading cases of liquor averaging 40 to 50 pounds from a truck, involving lifting cases onto a hand truck and pushing them to a storage area.

A. Yes. She may have problems with that.

Q. Doctor, did you determine whether or not this individual had any arthritic condition?

A. Well, on her X‑rays she did have degenerative changes of the spine. Arthritis by definition really begins in everybody after age 25; so if you are asking me by definition of the fact of the age group she is in, yes, she has arthritis.

Q. Can you tell me whether or not in your opinion this woman who has worked approximately 13 years as an employee of the Pennsylvania Liquor Store in the course of her employment of doing these job tasks, some of which I just described to you, could have aggravated her preexisting arthritic condition?

MR. STANTON: Note an objection to the form. You can answer.

BY MR. COLLINS:

A. In her thumb?

Q. That is correct.

A. Yes.

Q. What is your opinion?

A. Yes. She could have.

Q. Do you have an opinion based upon a reasonable degree of medical certainty as to whether or not she did aggravate her underlying arthritic condition?

MR. STANTON: In what area?

MR. COLLINS: Her thumb.

BY MR.COLLINS:

A. Yes.

Q. That opinion is?

A.  Yes.

Q. Is she still suffering from that aggravation presently as we speak, or as of your last examination?

A. She still has symptoms, yes.

Q. You also indicated that she has a condition known as spondylolisthesis and degenerative disc disease of the lumbar area.

A.  Yes.

Q. Can you tell me whether or not you have an opinion as to whether or not Debra Foster aggravated that preexisting condition in the course of her employment, again, keeping in mind those job descriptions that I asked you to review, specifically, lifting cases of liquor in excess of 40 to 50 pounds?

MR. STANTON: Note a continuing objection of the description as inappropriate to this particular person.

BY MR. COLLINS:

Q. Let me resolve that. Let me show you what has been previously marked as Claimant’s Exhibit No. 4 in the deposition of

Dr. David Branson. Take a look at that.

A.      Sure.

Q. Maybe you can review that so you can get an idea of what the job duties will be testified to by the Claimant as well as representatives of the Liquor Control Board.  Can you tell me, taking into consideration particularly the requirement for Debra Foster to be lifting cases of liquor in excess of 40 to 50 pounds, stacking cases of liquor as high as six feet for a period of an hour, and unloading cases of liquor averaging 40 to 50 pounds from a truck, and lifting those onto a hand truck, and pushing them to a storage area, whether or not those work activities aggravated her underlying spondylolisthesis?

MR. STANTON: Before you answer, Doctor, I want to note a continuing objection.

While we acknowledge that as a description of the job duties, it is our position that that job description is not appropriate for this particular individual and that allotments were made by the co‑employees given her age before any work related injuries were even contemplated.

BY MR. COLLINS:

Q. You can answer, Doctor.

A. No, it did not aggravate the spondylolisthesis. That’s a congenital problem.

Q. Am I understanding that any lifting of objects cannot aggravate that condition?

A. Cannot make it worse, no.

Q. So that’s a progressive condition that cannot be made worse by any outside criteria?

A. No. It is not a progressive thing. In other words, it is there.

Q. Does it wax and wane in general terms, or is it constant?

A. No. It can be painful when you put people in positions that cause stress on the spondylolisthesis. You can cause discomfort, but it doesn’t make the spondylolisthesis worse. And trauma may. A bad automobile accident, something like that can do it.

Q. So you are saying the condition is always there, but at certain times you can put some external cause to make it asymptomatic to symptomatic?

A. Yes, like having angina. You have problems with your heart—your blood vessels in your heart. Okay. Walking down a block may not bother you, but walking up stairs may cause some chest pain.

Q. Lifting cases of liquor on any type of repetitive basis or in excess of or up to an hour or stacking cases of liquor, would that have the ability to make that a symptomatic condition become symptomatic?

A. If she goes into an extension of the lumbar spine, it could cause symptoms; but it won’t worsen the spondylolisthesis.

Q. So, it won’t worsen the condition, but it will make it symptomatic?

A. Yes. It can bring about her symptoms.

Q. It can cause her discomfort and pain; is that correct?

A.  Yes.