In this case study, a neurologist expert witness opines on the allegedly debilitating pain of the plaintiff. The plaintiff was 59 years old when the motorcycle she was riding collided with another vehicle, which sent her sprawling across the road. She was treated in the emergency room for a fracture of her left fibula, hematoma in her right calf, and numerous abrasions. As a result of injuries she sustained during the accident, she now walks with the assistance of a cane and has been unable to return to work, since she suffers from continual pain in her left leg. Plaintiff sued the defendant driver for negligence in the Pennsylvania Court of Common Pleas.
Question(s) For Expert Witness
- 1. What is plaintiff’s diagnosis?
- 2. Has she received appropriate medical care?
- 3. Are additional tests necessary?
Expert Witness Response
A few days after the accident, an arterial Doppler showed plaintiff had a post-traumatic left saphenous neuropathy. She underwent physical therapy for 26 visits. She took Neurontin and Celebrex. A pain specialist diagnosed her with a left saphenous nerve neuropathy and causalgia of the left lower limb. The treating physician recommended more aggressive physical therapy and prescribed Tramadol for pain.
Plaintiff has not had a nuclear bone scan to see if there are findings that would support the diagnosis of causalgia. She has not had a QSART test. I would emphasize that the fibular fracture was closed and did not require surgery. She did have one injection into her left knee, and Plaintiff ambulates independently with an assistive device. Her abnormalities are limited to the left leg. She has full neck motion, full back motion and no straight leg raising pain. She has no atrophy in either leg. It is hard to test weakness in her left leg because she is very sensitive to touch, but when she is diverted I do not think she has focal muscle weakness. The skin around her knee is slightly mottled, more proximally in her thigh and more distally in her calf it is not mottled. There is no swelling in her left leg. It is slightly colder than her right leg. The dorsalis pedis pulses in both feet are the same. The patellar and Achilles reflexes are 1+ and symmetrical in both legs. There are no Babinski signs. There is no evidence of temperature change, mottling or swelling in her right leg or upper extremities.
Examination of plaintiff suggests a mild degree of skin mottling and slightly lowered temperature in her left leg. There is no swelling. She has good pulses. There is normal strength and no atrophy. These are symptoms of early reflex sympathetic dystrophy or overactivity of the sympathetic nervous system in the left leg. This would mean that she constantly has too much blood flow in the leg causing it to be mottled, swollen and occasionally cold. This type of injury usually occurs with traumatic injuries, usually with open injuries or injections. What is surprising to me is that none of her current treating physicians have suggested further workup to confirm the diagnosis, such as a QSART test or triple phase bone scan. More importantly no one has tied a stellate ganglion block to see if the mottling would go away and the leg would warm up and if that would potentially be a more permanent solution. I strongly suggest this.
Her symptoms are likely due to the accident. She currently has early reflex sympathetic dystrophy, however, if it is not stopped by the block that I suggested it can get worse. Her treatment to date has been reasonable and appropriate.