Worker's Compensation For A Shoulder Injury: Why The MRI Gets Your Claim Denied And What A Shoulder Is Worth When It Isn't

A shoulder claim is turned down more often than a wrist or a knee claim from the same warehouse and the reason is written in the MRI report. The radiologist will describe what is in the joint, the adjuster will find the word degenerative and the denial letter will say the condition was there before the lifting incident and would have been there without it. Before any of that is argued, here is what the argument is over:

Full-thickness rotator cuff tears are present in a large share of shoulders that have never hurt and the share rises with every decade after 50, which is the study base every insurer works from.
The rule that answers it, in federal and in state systems alike, is aggravation: a work event that turns a silent condition into a painful one is a compensable injury, whatever the joint looked like the day before.
When a claim is accepted and the shoulder has healed as far as it will, it is rated under the AMA Guides as a percentage of the arm and on the federal schedules the arm is 312 weeks of benefits. A typical repaired cuff tear rates at 5 to 7 percent, so 16 to 22 weeks.

The Word In The Report That Starts The Denial

A worker who has been reaching overhead all shift, feels the shoulder go while pulling a pallet down and is sent for an MRI three weeks later will get a report which describes, in this order, tendinosis, a partial or full-thickness tear of the supraspinatus, possibly some fluid in the bursa and acromioclavicular joint arthrosis. Two of those four findings are labelled degenerative by convention and the tear is usually described without a date, because a radiologist reading a static image cannot tell a tear that happened on a Tuesday from one that had been there for years.

The insurer’s medical reviewer then has a citation ready. In the Minagawa mass-screening study from 2013, 664 people in one Japanese village were scanned regardless of symptoms and 22 percent of them had a full-thickness cuff tear: none in their twenties through forties, 10.7 percent in their fifties, 15.2 percent in their sixties, 26.5 percent in their seventies, 36.6 percent in their eighties and among those over 60 the silent tears outnumbered the painful ones two to one. An earlier ultrasound series by Tempelhof found tears in 13 percent of pain-free shoulders in the fifties, 20 percent in the sixties, 31 percent in the seventies and half of everyone over 80.

So the denial is not a lie. It is a true fact about the population being used to answer a question about one person and the question that decides the claim is a different one: was this shoulder working before the incident and did it stop working because of it?

Aggravation Is The Rule That Answers It

Every worker’s compensation system in the country, the federal ones included, pays for the aggravation of a pre-existing condition. The Employees’ Compensation Appeals Board, which hears federal claims under FECA, has said in decision after decision that an employment injury which aggravates, accelerates or precipitates an underlying condition is compensable and that the employer takes the worker as it finds him. State boards apply that principle in their own words, some with a requirement that the work be a major contributing cause, most with a requirement only that it be a contributing one.

What that means for the shoulder is that the degenerative findings do not have to be disproved. They have to be made irrelevant, by showing that the joint was functional before and is not functional after and that the change tracks the incident rather than the calendar.

What The Treating Doctor’s Report Has To Say

A date and a mechanism. “Onset while lowering a 60-pound case from the top shelf on the morning of the 14th” is a claim. “Gradual onset of shoulder pain” is a denial waiting to be written, even if it is true, because gradual onset with no incident is exactly what the age studies describe and the reviewer will say so.
Pre-injury function, in the doctor’s words, not the patient’s. No prior treatment, no prior imaging, no restrictions, full duty for however many years.
The causation sentence, written to the legal standard: that the work incident more likely than not caused or aggravated the condition. A report which says the tear “could be” work related or “may have been” aggravated, has not met the standard in most systems and a reviewer who has read a thousand of these will quote it back.
If there was prior shoulder trouble, it goes in the report rather than being left for the carrier to find, with the doctor’s opinion on why the current condition is different in kind or degree.

A report that carries those four things has turned the MRI from the carrier’s evidence into yours, because those degenerative findings are now the condition that the incident aggravated.

The Repetitive Claim Is Harder, Not Impossible

Where there is no single incident, the claim is for an occupational disease or cumulative trauma and the age studies weigh more heavily against it. What carries it is the job description, set out in detail: hours per shift above shoulder height, weights, frequency, years and a physician willing to say that the exposure was the more probable cause of the symptomatic tear than the worker’s age alone. The Minagawa data help here as well, since the same paper found that heavy labor, the dominant arm and a history of trauma were the factors that went with tears becoming symptomatic.

Injury	What the MRI usually shows	What the carrier writes	What makes it compensable anyway
Rotator cuff tear	Tendinosis, partial or full-thickness supraspinatus tear	Degenerative, age-consistent, pre-existing	Documented incident, no prior symptoms, causation sentence to the standard
Labral tear (SLAP)	Superior labral fraying or detachment	Chronic, attritional, common in overhead workers	Acute mechanism (traction, fall on outstretched arm), age under 40 helps
Impingement and bursitis	Bursal fluid, acromial spur	Anatomic, not traumatic	Repetitive overhead exposure quantified, symptom onset tied to a change in duties
AC joint separation	Widened AC interval, ligament disruption	Rarely disputed	Fall or direct blow, almost always accepted
Proximal humerus or clavicle fracture	Fracture line	Rarely disputed	Accepted; the fight moves to the rating

What The Shoulder Is Worth Once The Claim Is Accepted

Wage loss during recovery and the medical bills are paid as they come. The number people are searching for is the permanent one, paid when the doctor declares maximum medical improvement and rates what is left.

The rating is done under the AMA Guides to the Evaluation of Permanent Impairment, sixth edition in the federal systems and in most states, a few states using the fourth or fifth. The shoulder is rated in Table 15-5, the Shoulder Regional Grid, as a percentage of the upper extremity. A full-thickness rotator cuff tear with residual symptoms and normal motion sits in class 1 with a default of 5 percent of the arm, adjusted one grade either way for pain and examination findings, so 4 to 7 percent is the usual outcome. A partial-thickness tear defaults to 1 percent. Where motion has been lost, the doctor may rate by range of motion under Table 15-34 instead and a stiff shoulder after repair can reach 10 percent or more that way. Class 2 and 3 ratings, 14 to 49 percent of the arm, are reserved for failed repairs, arthroplasty and instability.

The percentage becomes money through a schedule. Under FECA, 5 U.S.C. 8107(c)(1) and under the Longshore Act, 33 U.S.C. 908(c)(1), the arm is worth 312 weeks of compensation, so a 6 percent rating pays 6 percent of 312, which is 18.7 weeks, at the statutory rate of two-thirds of the average weekly wage. State schedules use different week counts for the arm and different rates, but the arithmetic has one shape everywhere: percentage of the member, times the weeks the schedule gives that member, times the weekly rate.

Outcome at maximum medical improvement	AMA Guides sixth edition rating, upper extremity	Weeks on a 312-week arm schedule	What moves it
Partial-thickness tear, treated without surgery	1 to 2 percent	3 to 6 weeks	Persistent pain modifier
Full-thickness tear, repaired, normal motion	4 to 7 percent	12 to 22 weeks	Grade modifiers for pain and atrophy
Repaired tear with lost motion	8 to 12 percent by range of motion	25 to 37 weeks	Measured degrees of flexion, abduction, rotation
Failed repair or arthroplasty	14 to 49 percent, class 2 or 3	44 to 153 weeks	Stability, strength, second surgery

A denied claim is worth none of that, which is why the report described above matters more than any negotiation that comes after it.

Where The Two Halves Meet

The workers who lose most on shoulders are not the ones with the worst injuries. They are the workers in their fifties with a real incident, a real tear and a doctor who wrote “degenerative changes with possible aggravation” and left it there. The adjuster accepts the medical bills for a few weeks, denies the tear and the rating never happens because there is nothing accepted to rate.

If a claim is at that stage, the work is to get the treating physician to write the causation sentence properly or to obtain a second opinion from someone who will and to have the pre-injury work history put into the record before the insurer’s independent examiner sees the file. That is the point at which a workers’ compensation attorney earns the fee, because the record that gets a shoulder claim accepted has to be built in the first two months and an examiner who is handed a thin file in the third is going to write to the age studies.