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Sunday, June 30, 2013

Rotator Cuff Tear: Understanding This Common Occurrence in Personal Injury

Rotator Cuff Tear:  Understanding This Common Occurrence in Personal Injury

Dr. Alan Himmel

Anyone who has ever treated or represented a person with a rotator cuff tear, is fully aware of the troublesome nature of this injury.

But, what do we really know about this traumatic condition?

First, a little anatomy:  The rotator cuff is group of four muscles.  They are the Supraspinatus, Infraspinatus, Teres minor, and Subscapularus.  For purposes of remembering these muscles, just think "SITS."  This is an easy mnemonic, which any student of anatomy should remember.  The names of these muscles, like a lot of structures in the body, often tell a little bit about where they are located within the body.  For example, "supra"-spinatus is located superior to the "spine" of the scapula.  The "infra"-spinatus is located inferior to the "spine" of the scapula.  The "sub"-scapularus is located behind or deep to the scapula.

These muscles, like all skeletal muscles have a function, and they are to move bones by pulling on them, and also help give support to the bony structures of the body. Skeletal muscles must connect to bones in order to be able to pull on them, and they are connected by way of tendons.  The tendon on a muscle is what actually connects the muscle to the bone.  Unlike muscle which can contract and stretch, tendons do not have this ability.  They are simply there to connect the two structures together.  They are generally in-elastic and are very strong.

Notice the white colored tissue?  These are the tendons of the SITS muscles, and these tendons are connecting to the head of the humerus.  They will cause movement as well as to help to stabilize the joint and hold it in place.

The SITS muscles control very specific actions of the shoulder. And, the supraspinatus muscle is of most interest, because its the most commonly injured of the SITS muscles. The supraspinatus controls the action such as raising the arm out to the side (abduction) and turning the arm backward (external rotation). Because of this motion, one can easily see the stress it would be under, by a baseball pitcher, for example.
Abduction and external rotation of shoulder

So, where is the injury?  Where is the "tear?"

Most commonly, the rotator cuff injury is to the supraspinatus tendon.  Again, this tendon connects the supraspinatus (which sits above the spine of the scapula) and connects to the head of the humerus.  And more specifically, its the far end or distal end of the tendon, very close to the humoral head.   There is a small area that is known as the "critical zone" which is an area within the actual tendon that is much less rich in blood supply. This area of hypovascularization is a weak spot on the tendon because it is not supplied by rich blood, to the same extent as other parts of the tendon and muscle are.  It is thought that this is the reason most of the tears occur in that area.



What else can cause a traumatic tear of the supraspinatus besides a sports injury?  Falling on an out stretched arm can cause a tear.(1)  Sometimes when the person falls, the collarbone is fractured or the gleno-humeral joint (shoulder socket) is dislocated at the same time as the tear, although it is not necessary to have a fracture at the same time as the tear.  I have had a few patients over the years who have experienced a fall which resulted in a torn supraspinatus tendon.  In fact, in my personal experience the damage to the tendon is more common in falls than in sports related, or repetitive motion activities.  

The impairment and  treatment are almost always the same.  Usually the patient presents with pain, weakness, los of motion, and swelling in the shoulder.  They tell me they cannot take a gallon of milk out of the refrigerator with the affected shoulder.  Treatment consists of anti inflammatory modalities including icing.  Non steroidal anti-inflammatory medication is suggested.  Strengthening exercises are started.  

The MRI is the diagnostic type that is best suited to definitively diagnose the tear, since the injury is soft tissue in nature.(2)  X-ray very often turns up nothing unless there is a fracture of the humeral head where the tendon attaches, the collar bone is broken, or there is a dislocation.  

Clinical correlation is important.  When did the patient first start feeling the pain?  How was the shoulder prior to the fall?  Did the patient have his arm outstretched at the time of the fall?  All good questions and part of the patient history.

I always suggest the least invasive and safest treatment options for my patients first, but sometimes if strengthening and rehabbing the torn tendon fails, the next step is that the patient tries cortisone injections and unfortunately, surgery may become part of their future.

How this injury will affect the patient in the future is important to document.  The shoulder is never exactly the same as before the tear.  There is always some degree of pain and loss of range of motion.  Frequent exacerbations due to use of the shoulder are common.  Is the patient dominant handed on the side of the injury?  If so, the impairment will be more significant.  Will the injury have any impact on the future income of the patient?  Sometimes this is yet to be determined.

My contact information is:






1.   2013 Feb;29(2):366-76. doi: 10.1016/j.arthro.2012.06.024. Epub 2013 Jan 3.An evidenced-based examination of the epidemiology and outcomes of traumatic rotator cuff tears.
Sports Medicine Program, Rush University Medical Center, Chicago, Illinois 60612, USA.


2.   2012 Dec;20(3):361-4.
Non-contrast magnetic resonance imaging for diagnosing shoulder injuries.
Arnold HOrthopaedisch - Unfallchirurgische Praxisklinik, Orrthopaedisches Zentrum Fichtelgebirge, Rehau, Germany.

Thursday, June 13, 2013

Florida PIP No-Fault Blog--This Weeks Search Queries.

Top Search queries which brought people to the Florida PIP No-Fault Blog.

Dr. Alan Himmel

June 13, 2013.  

Q:  Can an 18 year old get only PIP insurance?
A:  No.  The minimum coverage in the State of Florida is PIP and PD.  Everyone must have at least personal injury protection and property damage liability coverage.  

Q:  "EMC doctors in Pembroke Pines Florida"
A:  Right now, the way it stands, the EMC diagnosis may not be needed.  There has been a temporary injunction to parts of the no-fault law.  However, many attorneys are still recommending patients see an MD if there is a need for documenting an emergency medical condition.  The problem is that some insurance companies may try to enforce the EMC rule, and without it, the patient is left with only 1/4 the coverage that was paid for.  To be sure, however, if I were you, I would ask an attorney.  

Q:  "Car accident 14 day treatment"
A:  This person probably wasn't sure, but he heard that PIP treatment must commence by 14 days of an accident.  Correct!  You have 14 days to begin care.  If you went to the hospital, this counts.  Also, your family doctor, chiropractor.  This is one part of the no-fault law that was not contested.  It still stands.

Q:  "Florida EMC form for accidents"
A:  The Florida Department of Financial Services or any insurance company as far as I know have NOT created an EMC form.  I have googled it for months now, and not once have I seen a standard form for the EMC.  Remember, also, the EMC requirement is likely ON HOLD for the time being.  You should check with your attorney on this.

Q:  "Car accident Florida Massage therapy pain"
A:  If you are wondering if massage is covered under PIP, yes, the temporary injunction to the new PIP law is allowing massage like it always has.  However, some lawyers still recommend staying away from massage since there will be a few insurance companies that will try to deny medical claims for massage services.

Q:  "Will PIP pay my medical bills after IME" 
A:  IME stands for independent Medical Exam.  Insurance companies will send claimants to a doctor to get a second opinion.  This almost always means that the patient's coverage will be terminated after the exam, because the IME doctor almost always states that the patient can no longer benefit from care.  I have never let this exam limit my patient's access to treatment if the patient and I think it's needed.  The insurance company will usually send out a letter to the patient which states there is no more coverage, and this very often dissuades the patient from continuing even if they truly need the care.  They are afraid of being stuck with a bill they cannot pay.  Come see me at my office.  954-659-8600 Dr. Himmel

If your benefits are terminated by your insurance company, I have been very successful in getting the treatments paid for anyway.  Just call me.  I will see what I can do.

Wednesday, June 5, 2013

Simple Trick to Get More Money for Your Totaled car.

Negotiating your total loss.


Dr. Alan Himmel

If your car was totalled in a car accident, do you have to accept the first offer that your insurance company makes?  I think not.  Most people do accept the first offer, however, by doing this, they may be leaving a good amount of money on the table that belongs to them.  Over the years, I have helped many patients get more money when their car was deemed a total loss.  You don't need to be a master negotiator, nor do you need to be a lawyer to do this.  There is a trick, and I will tell you how it works:

First, it helps to have some knowledge of the way insurance companies process claims.  I happen to be a licensed public insurance adjuster, aside from being a chiropractor, so I have some first hand knowledge of this procedure.  You have to know that most auto insurance companies process property claims based on what's called Actual Cash Value or ACV.  What this term basically means is that the insurance company will value your property based on what the current market rate is for that particular property.  You just ask yourself, "what would I have to pay right now today, to replace this car?" This little piece of valuable information regarding ACV is written into your policy.  It's in the boring part that most people never read.

Here is an example of the way ACV works:  If you buy a car in 2003 for $20,000, and you file a claim for a total loss of that car in 2013, provided you have coverage, the insurance company will use a system of multiple sources to determine what it would cost to replace that same exact car, now, in 2013.  So, unless you got a banging deal on that car, or its a one of a kind collector's car, most likely the car is worth less than the $20,000 that you paid; the car has to be worth less because of 10 years of depreciation.  Their system will determine what the market price in your area is for that car.

Now, there are a few things to consider here:  You must consider the deductible on the policy.  If you are filing the claim through your own policy, you most likely have a deductible and that would be subtracted from the amount they determine the car is worth.  If you file through the at fault carrier, then there is NO deductible.  The claim is paid at 100%.  Next, the insurance company has to pay you the applicable tax on top of the amount they decide to pay you.



So, here is a breakdown.   Hypothetical numbers:

2003 Car purchased for $20,000.00
2013 Car total loss
2013 ACV of the car is    $4,500.00
Policy deductible  is          $ 500.00
Carrier pays                   $4,000.00
Applicable Tax is               6% (FL) or $240.00

Carrier sends a check for $4240.00

Okay, here is the simple trick that works, in my experience, at least 75% of the time to get more money:  What you simply do is look in as many places as possible including the autotrader, the classified ads, and the flyer and try to find your car with similar mileage and specs, for a higher price than what the insurance company is paying.  You then clip those ads.  Get as many as you can find but if you only find 2 or 3, this may be enough.  Next, you need to forward the ads to the claims adjuster showing that in YOUR market, it would be impossible to replace the car for what they allowed.

Sometimes I have seen that the insurance company is actually very fair with their allowance, and sometimes believe it or not, the insurance company is actually pays more than what it would cost to replace. In either of these cases, just take what they are allowing. (Don't try and negotiate down!)

Like I have said.  About 75% of the time it works out in your favor and you can expect to receive a supplemental check in the mail of sometimes over $1000.

Better in your pocket than theirs.  Good Luck.