before the iowa industrial commissioner
            WILLIAM D. BURGDUFF,          :
                 Claimant,                :
            vs.                           :
                                          :         File No. 776776
            BILL BRADY & SONS             :
            CONSTRUCTION,                 :      A R B I T R A T I O N
                 Employer,                :         D E C I S I O N
            and                           :
                 Insurance Carrier,       :
                 Defendants.              :
                              statement of the case
                 This is a proceeding in arbitration brought by claimant 
            William D. Burgduff against defendant employer Bill Brady & 
            Sons Construction and defendant insurance carrier Cigna 
            Insurance Companies to recover benefits under the Iowa 
            Workers' Compensation Act as the result of an injury 
            sustained on September 18, 1984.  This matter came on for 
            hearing before the undersigned in Des Moines, Iowa, on April 
            20, 1989.  The matter was considered fully submitted at the 
            close of evidence.
                 The record in this proceeding consists of claimant's 
            testimony and joint exhibits 1 through 25.
                 Pursuant to the prehearing report submitted by the 
            parties and approved at hearing, the following issues have 
            been stipulated:  that an employment relationship existed 
            between claimant and employer at the time of the injury; 
            that claimant sustained an injury arising out of and in the 
            course of that employment relationship on September 18, 
            1984; that the injury caused temporary and permanent 
            disability; that the work injury caused a scheduled member 
            disability to the right leg; that the appropriate rate of 
            weekly compensation is $326.54; that defendants are entitled 
            to credit pursuant to the industrial commissioner's 
            supplemental claim activity report 2A (which shows payment 
            of 116 weeks, 4 days healing period and 92 weeks, 4 days 
            permanent partial disability, or 42 percent of the leg).
            Page   2
                 Issues presented for resolution include: the extent of 
            claimant's entitlement to compensation for healing period 
            benefits; the extent of claimant's entitlement to 
            compensation for permanent disability benefits and the 
            commencement date thereof; the extent of claimant's 
            entitlement to medical benefits (although it was stipulated 
            that the fees charged for medical services or supplies are 
            fair and reasonable).  In addition, claimant seeks an order 
            requiring defendants to provide future medical services by 
            way of surgery to remove screws inserted surgically in his 
            right leg.
                 By Order of October 18, 1985, claimant's claim for 
            penalty benefits under Iowa Code section 86.13 was severed 
            from issues of compensability.
                              review of the evidence
                 Claimant testified that he sustained an injury to his 
            right knee climbing down from an earth moving machine on 
            September 18, 1984.  He first saw James E. Dolan, M.D., his 
            family physician.  Dr. Dolan treated claimant with rest.  
            Approximately one month later, Dr. Dolan referred claimant 
            to Marshall Flapan, M.D.  Dr. Flapan took x-rays and 
            examined claimant's knee arthroscopically, but did not 
            perform a repair.
                 Claimant testified that after he was released by Dr. 
            Flapan he still suffered pain and did not return to work.  
            By recommendation of his attorney, claimant visited Kent 
            Patrick, M.D., an orthopaedic surgeon.  Dr. Patrick treated 
            claimant with physical therapy for some months before 
            eventually performing an anterior cruciate repair on January 
            16, 1986.  Thereafter, Dr. Patrick had claimant undergo 
            further physical therapy with a therapist in his office, 
            which continued until approximately February, 1987.
                 Dr. Patrick moved out of state during the course of 
            claimant's treatment, following which his care was 
            transferred to Peter D. Wirtz, M.D.  Claimant indicated that 
            he saw Dr. Wirtz approximately two times as of December, 
            1986, when that physician advised claimant he had reached 
            maximum improvement in approximately September of that year.
                 Claimant indicated that he discontinued physical 
            therapy in February, 1987, when the therapist advised him 
            that he needed a new prescription.  Claimant indicated he 
            did not return because Dr. Wirtz had already advised him 
            that his maximum improvement had already been reached.  
            Also, claimant believed the exercise was exacerbating his 
            knee condition.  However, claimant indicated that pain 
            increased gradually after he discontinued physical therapy.
                 Claimant next visited physical therapist Thomas Bower 
            on the advice of his attorney.  Dr. Bower referred him to 
            physician Mark Kirkland, M.D., an orthopaedic surgeon.  
            Page   3
            Claimant indicated that he was advised by Dr. Kirkland that 
            he should have metal screws inserted at the time of his last 
            arthroscopic surgery removed.  Claimant wishes to undergo 
            that surgery.
                 Claimant testified further that he had been essentially 
            unemployed since December, 1986, although he has not 
            specifically kept track of what intermittent work he has 
            done.  He has never worked two weeks in a row.
                 In addition to treatment for claimant's knee, Dr. Dolan 
            treated claimant for an ulcer condition.  Claimant admitted 
            on cross-examination that Dr. Dolan had treated him for 
            similar problems in 1983 with similar medication.
                 Claimant further testified that he had personally paid 
            medical expenses for prescriptions set forth in exhibit 23, 
            all medications prescribed by Dr. Dolan and subsequent 
            treating physicians.  Claimant has also not been reimbursed 
            for Dr. Dolan's bills of $187.50 or mileage expenses for 208 
            miles.  Dr. Dolan's billings contained in exhibit 22 
            indicate that at least some of his charges were paid by 
            defendants.  Dr. Dolan treated claimant both for his knee 
            and for a duodenal ulcer.  Dr. Dolan wrote claimant's 
            attorney on October 14, 1985 to note that claimant had been 
            treated with anti-inflammatory and pain medications for his 
            knee and medications and gastroscopy for the ulcer.  He 
            specified that the ulcer and depression were directly 
            related to stress associated with the work injury, and that 
            in particular medications and treatments were directly 
            related to the injury.
                 Dr. Dolan's chart notes reflect that he prescribed a 
            number of medications including Limbetrol, Tagamet, Tylenol 
            III, Zantac, Velosef and Fiorinal.
                 Dr. Flapan performed arthroscopy of the right knee on 
            November 7, 1984.  His diagnosis was partial rupture of the 
            anterior cruciate ligament.  Dr. Flapan subsequently 
            executed a release for claimant to return to work on 
            November 26, 1984.  The release was not specific as to 
            whether claimant was able to return to light duty or his 
            regular work duties effective November 26, 1984, but chart 
            notes of November 19 indicate a release to unrestricted 
                 Dr. Flapan wrote on July 2, 1985 that claimant had 
            sustained a rupture of the anterior cruciate ligament as a 
            result of the work-related injury and had sustained a 15 
            percent permanent partial impairment to the right lower 
                 Kent M. Patrick, M.D., was associated with Peter D. 
            Wirtz, M.D., in an enterprise known as Orthopaedists 
            Limited.  He wrote claimant's counsel on May 29, 1985 to 
            note that he had first seen claimant on April 15 of that 
            year.  He felt that claimant's present problems were related 
            Page   4
            to the work injury.  He expected claimant to improve, but it 
            was unknown at that time whether surgical intervention would 
            be necessary.
                 Dr. Patrick's chart notes of April 15, 1985 reflected 
            that claimant was being set up for daily physical therapy.  
            Subsequent notes throughout 1985 reflect that claimant first 
            showed improvement, but thereafter some regression or lack 
            of further progress.  On a diagnosis of (1) right anterior 
            cruciate ligament insufficiency and (2) grade II 
            chondromalacia right lateral tibial plateau, Dr. Patrick 
            performed surgery on January 16, 1986 consisting of:  (1) 
            right knee operative arthroscopy with partial synovectomy 
            and (2) anterior cruciate ligament construction.
                 Dr. Patrick's operative notes reflect in part that 
            "instead of Benel sutures, the cancellous screws with 
            ligamentous washers were utilized to secure the ileal tibial 
            band to the distal femur."
                 Postoperative chart notes prepared by Dr. Patrick 
            and/or Dr. Wirtz reflect improvement of claimant's range of 
            motion through physical therapy.  As of April 18, 1986 
            claimant had flexion to 110 degrees.  On May 9, 1986 he had 
            attained 115 degrees of flexion and minus 10 degrees of 
            extension in therapy, but claimant "still has a long ways to 
            go in terms of getting further motion and strength in the 
            extremity."  On May 30 claimant had flexion to 117 degrees 
            and extension to minus 5 degrees.  On July 10, 15 degrees to 
            110 degrees; July 23, 12 degrees to 120 degrees; August 29, 
            8 degrees to 120 degrees; and, on October 17, 1986, 5 
            degrees to 125 degrees.  Notes of that date indicate that 
            this 30 degree loss of motion constituted an 11 percent 
            impairment of the lower extremity and that continued 
            quadriceps muscle atrophy constituted a 4 percent impairment 
            of the lower extremity for a total of 15 percent impairment.  
            "This patient's condition has reached a plateau in the 
            rehabilitation and it is not anticipated that it will 
                 Peter D. Wirtz, M.D., wrote on September 26, 1986 that 
            claimant's range of motion was 5 degrees to 125 degrees and 
            that claimant was capable of employment with restriction of 
            forceful pushing of his leg on the right.  Dr. Wirtz 
            indicated that the patient would regain strength in the 
            distant future.
                 Tim Alberhasky, M.S.P.T., of Physical Therapy and 
            Sports Center (which shares an address with Orthopaedists 
            Limited), noted on December 4, 1986 that claimant had 
            demonstrated an improvement in both strength and endurance 
            activities since his previous test on October 10 of that 
            year.  On February 13, 1987, the last such test, Mr. 
            Alberhasky noted that claimant demonstrated improvement in 
            strength levels of the right quadricep muscle group of eight 
            percent since his last testing on January 6 of that year.  
            Page   5
            Claimant continued to present significant deficits when 
            compared to his normal left leg.
                 Dr. Wirtz saw claimant again on January 25, 1988.  He 
            subsequently wrote on February 5:
                 This patient was seen 1/25/88.  His diagnosis 
                 includes right knee anterior cruciate ligament 
                 rupture with reconstruction, quadriceps muscle 
                 atrophy, and loss of motion right knee secondary 
                 to surgical procedure.
                 This patients [sic] range of motion is 15 degrees 
                 to 95 degrees which is an 80 degree loss of motion 
                 which is a 25% impairment of the right lower 
                 extremity.  This patients [sic] quadriceps muscle 
                 continues to show weakness secondary to the loss 
                 of motion and the ligament injury which is a 5% 
                 impairment of the lower extremity.
                 This patient has a condition of the anterior 
                 cruciate ligament rupture with the associated 
                 stiffness and weakness and this also relates to a 
                 10% impairment of the lower extremity.
                 The total impairment related to the anterior 
                 cruciate ligament rupture and surgery, loss of 
                 motion, and weakness of the muscle is a 40% 
                 impairment of the right lower extremity.
                 The medical management at this time would be 
                 continuation of a home educated physical therapy 
                 program for range of motion and strength to the 
            (Joint exhibit 11, page 2)
                 Thomas W. Bower, L.P.T., saw claimant on December 17, 
            1987.  He found range of motion actively from 25 to 100 
            degrees.  Strength was only 50 percent of the uninjured 
                 Mark B. Kirkland, D.O., saw claimant on February 10 and 
            12, 1988.  He wrote on the latter date that claimant could 
            actively flex his knee to 107 degrees, but passively to 125.  
            However, after the knee was injected with anesthetic, 
            claimant could actively flex to 115 degrees.  Claimant 
            stated that he had 100 percent pain relief.  Claimant had 
            shown marked tenderness to palpation over the screws in the 
            distal lateral femur.
                 Dr. Kirkland's notes reflect that he saw claimant again 
            on March 20, 1989.  Claimant had flexion of the knee to 117 
                 Dr. Wirtz testified by deposition taken April 7, 1989.  
            Dr. Wirtz testified that he is an orthopaedic surgeon 
            Page   6
            certified by the American Board of Orthopaedic Surgery.  He 
            indicated that claimant first became a patient of the office 
            on April 15, 1985, eventually undergoing surgery at the 
            hands of Dr. Patrick.  Dr. Wirtz took over treatment from 
            Dr. Patrick on July 10, 1986.
                 Asked when claimant reached a plateau when no 
            significant medical improvement was anticipated, Dr. Wirtz 
            answered that based on the October 10, 1986 Cybex test, the 
            period of healing would have been in September or October, 
            1986.  As of October 17, 1986, based on loss of range of 
            motion and muscular atrophy in the quadriceps, the doctor 
            felt that claimant had sustained a 15 percent impairment of 
            the right lower extremity.
                 Dr. Wirtz next saw claimant on January 25, 1988.  He 
            again evaluated the extent of claimant's permanent 
            impairment.  At this time, claimant exhibited only 80 
            degrees of motion of the right knee, a change in his 
            condition.  Based on the loss of motion and strength and 
            evaluating the anterior cruciate ligament instability, which 
            itself would add another 10 percent impairment, Dr. Wirtz 
            believed that claimant had at that time sustained a 40 
            percent impairment of the right lower extremity.
                 Dr. Wirtz saw claimant again on September 30, 1988.  At 
            that time there had been no change in claimant's condition 
            or the extent of his permanent impairment.
                 On cross-examination, Dr. Wirtz indicated that the 
            range of motion measured on September 26, 1986 of 120 
            degrees of motion "may not have been with a goniometer" and 
            "may have been essentially an estimate and not a 
            measurement."  Dr. Wirtz admitted that the 11 percent 
            impairment based on range of motion in 1986 was simply wrong 
            and that claimant's condition had not worsened at all 
            between October 1986 and January 1988.  The October 17, 1986 
            date was not an examination date, but was a conference date 
            with defense counsel and was based on a review of previous 
            records from September 26, 1986.
                 As to the screws that had been inserted by Dr. Patrick 
            on January 16, 1986 in his surgical reconstruction, Dr. 
            Wirtz was of the view that removal of the screws would not 
            aid motion, strength or change the diagnosis of anterior 
            cruciate insufficiency and would not benefit claimant.  He 
            agreed on cross-examination that if the motion of the knee 
            joint and muscle tissues rub over the top of the screw edge, 
            removal of the screw would reduce that particular irritation 
            and that if that irritation was significant, claimant would 
            possibly gain more strength, but would not regain more 
            motion.  When asked to comment on Dr. Kirkland having given 
            an injection over the screws which relieved irritation and 
            allowed better range of motion, Dr. Wirtz answered:
                 A.  If he gave the area a local anesthetic over 
                 the screws, and it numbed the area where the 
            Page   7
                 screws were irritating and it reduced his pain, 
                 then taking the screws out would reduce the pain.  
                 But I doubt if it would increase the range of 
                 motion, because the tissues that are scarred in 
                 that joint are not going to be that pliable.
                 Q.  If Mr. Burgduff could regain some strength in 
                 his leg, would that allow him to better push on 
                 pedals and climb ladders and perform his daily 
                 work activities?
                 A.  The last Cybex test I have to review is one 
                 done on April 12, '88 of his leg which shows him 
                 to have a weakness of 35 percent, which is 
                 consistent with his rehabilitation for his 
                 problem, and our best results would hope to get 
                 strength up to the point of maybe still having 20 
                 percent loss.
                 So if he gained more strength for one reason or 
                 another, I would say it probably would increase a 
                 slight degree; and, of course, any increase in 
                 strength would help him function better, yes.
            (Dr. Wirtz deposition, page 17, line 21 through page 18, 
            line 17)
                 However, Dr. Wirtz believed that the surgery to remove 
            the screws would be unlikely to increase claimant's strength 
            and he would not recommend it.  This was because, in his 
            view, claimant did not have symptoms related to the screws:
                 Q.  Why don't you think that the patient had pain 
                 because of the screws?
                 A.  Well, because he spoke with me specifically on 
                 1-25-88 and 9-30-88, and didn't mention specific 
                 pain related to those screws.
                 Q.  What did he tell you his problem were?
                 A.  On 1-25 he mentioned the difficulties of the 
                 right knee was stair climbing because of pain, as 
                 well as walking and standing, and also that the 
                 knee gave way, and that he had weakness of the 
                 Q.  You said he had pain, but because he didn't 
                 say, "I have pain where the screws are," you don't 
                 think he mentioned it to you?
                 A.  If he did have pain specifically from the 
                 screw irritation, he would point right to the area 
                 of the screw.
                 Q.  Do you know where he pointed?
            Page   8
                 A.  He didn't point anywhere.
            (Dr. Wirtz deposition, page 19, line 6 through line 24)
                 Dr. Wirtz also noted that the screws had been placed to 
            hold tissues for 12 weeks following surgery and beyond that 
            time have no benefit or function.  If the screws were to be 
            surgically removed, claimant would have restriction of 
            function for 6-12 weeks postoperatively to have complete 
            resolution of the surgical procedure, but "in all 
            likelihood" the procedure would not harm claimant.  However, 
            there does exist a potential for infection in the local area 
            of removal and a potential problem with loosening the 
            structures that have already been used to reconstruct the 
            anterior cruciate.  Dr. Wirtz described these potential 
            complications as rare and not to be expected in the normal 
            course of events.
                 Dr. Kirkland testified by deposition taken March 29, 
            1989.  Dr. Kirkland indicated that his particular 
            subspecialty is sports medicine, but that he practices the 
            specialty of orthopaedic surgery.  His curriculum vitae 
            shows that he is board-certified by the American Academy of 
            Neurological and Orthopaedic Surgeons and board-eligible 
            with the American Board of Orthopaedic Surgery.
                 Dr. Kirkland first saw claimant on February 12, 1988.  
            Claimant lacked 12 degrees of extension and could flex to 
            107 degrees actively, 125 degrees passively.  As noted 
            earlier, claimant was able to actively flex to 115 degrees 
            following injection.  X-rays were taken which showed two 
            bone screws in the distal lateral femur, no evidence of 
            arthritis and disuse osteopenia.  The doctor's impression 
            was of anterior cruciate deficient right knee and status 
            post extra-articular reconstruction of the right anterior 
            cruciate ligament.
                 Dr. Kirkland testified that he saw claimant again on 
            March 20, 1989.  Claimant's physical examination was 
            essentially the same.  He still had atrophy of the quadricep 
            musculature and tenderness over the screw sites.  Dr. 
            Kirkland's recommendation was the same:  removal of the 
            screws to help relieve pain.
                 Dr. Kirkland thought it significant that an injection 
            of anesthetic over the screw sites gave claimant 100 percent 
            pain relief.  This is so because it localized the area that 
            was giving claimant pain, and this was in fact the reason 
            for trying the injection.  Dr. Kirkland felt that the screws 
            were giving claimant pain because of impingement or rubbing 
            up and down by the tendons in the area, and removal could 
            help relieve pain and potentially increase range of motion.  
            Dr. Kirkland was able to say with a reasonable degree of 
            medical certainty that removing the screws would relieve 
            pain ("If he was my son, I would want to try and remove 
            these screws to see if this would help him at all.").  
            However, there could be some residual pain from the anterior 
            Page   9
            cruciate repair.  Furthermore, he could guarantee nothing as 
            far as improvement in claimant's range of motion.  
            Nonetheless, he felt there was potential of improving 
            claimant's rehabilitation because the pain he suffers in the 
            knee interferes with continued rehabilitation.  This is so 
            because if an individual has pain in a joint, there is a 
            natural reluctance to move the joint.  Dr. Kirkland's 
                 A.  My specific recommendations would be an 
                 outpatient procedure to remove his screws and to 
                 start him on a physical therapy program, number 
                 one, to build up his quadricep and hamstring 
                 muscle mass and hopefully to see if we could get 
                 any range of motion back.
                 I wouldn't want to guarantee that, by removing the 
                 screws, it would help him in his range of motion 
                 because a long time has lapsed and his joint could 
                 be ankylosed or fixed in this position.  But 
                 again, since he is still having pain, I feel I 
                 would suggest that screw removal would be 
                 appropriate treatment.
                 Q.  Is that recommendation reasonable and 
                 necessary medical care for this work injury?  In 
                 other words, is your recommendation for treatment 
                 causally related to the work injury described?
                 A.  Yes.
                 Q.  Do you expect improvement in Mr. Burgduff's 
                 condition if the recommended care and treatment 
                 takes place?
                 A.  I would expect improvement in his pain. * * *
            (Dr. Kirkland deposition, page 16, line 3 through line 24)
                 Joint exhibit 21 reflects unreimbursed bills from Dr. 
            Dolan of $187.50, unreimbursed charges from Kiburz Pharmacy 
            of $1,546.29, and 208 miles in medical related mileage from 
            May 24, 1987 through September 30, 1988.  Mileage claimed 
            includes 52 miles to visit Dr. Wirtz, 24 miles to visit Dr. 
            Dolan, 26 miles to visit Tim Alberhasky, 36 miles to visit 
            Thomas Bower, and 70 miles for several trips to Kiburz 
                           applicable law and analysis
                 The parties have stipulated to an injury arising out of 
            and in the course of employment and that the injury caused 
            both temporary and permanent disability.  The extent of each 
            remains in issue.
                 Pursuant to Iowa Code section 85.34(1), healing period 
            is payable until the employee has returned to work, it is 
            Page  10
            medically indicated that significant improvement from the 
            injury is not anticipated, or until the employee is 
            medically capable of returning to substantially similar 
            employment, whichever first occurs.  Claimant has not 
            returned to work and it does not appear that he is yet 
            capable of returning to substantially similar employment 
            because of his inability to operate a clutch pedal with his 
            right leg.  Therefore, healing period benefits are payable 
            until the date that significant improvement from the injury 
            was no longer anticipated.
                 Dr. Flapan released claimant to return to work 
            effective November 26, 1984.  The greater weight of the 
            evidence establishes that claimant was not truly able to 
            return to work at that time because he still needed 
            reconstruction of the anterior cruciate ligament in his 
            right knee.
                 Dr. Patrick eventually performed that repair on January 
            16, 1986.  Subsequently, Dr. Wirtz took over claimant's 
            care.  Dr. Wirtz expressed a view as to claimant's permanent 
            disability on October 17, 1986, but this was based on a 
            physical examination of September 26, 1986.  Dr. Wirtz was 
            of the view that claimant had reached maximum recovery as of 
            the latter date.  However, the record does establish to the 
            writer's satisfaction that claimant continued to physically 
            improve after that date, although his condition subsequently 
            deteriorated.  Claimant credibly testified that he continued 
            to improve while undergoing physical therapy through 
            February, 1987.  Therapist Tim Alberhasky reported on 
            October 10, 1986 that claimant had not significantly 
            improved since September 26, but found that claimant had 
            demonstrated improvement in both strength and endurance as 
            of December 4, 1986 and further improvement of strength as 
            of February 13, 1987.  An eight percent strength improvement 
            in the right quadricep muscle group must be considered 
            significant.  February 13, 1987 is the measurable "high 
            water mark" in terms of claimant's recuperation.  
            Thereafter, his condition deteriorated or was essentially 
            stable.  It is held that healing period began on the date of 
            injury and ended on February 13, 1987, a total of 125 weeks, 
            4 days.
                 The commencement date of permanent partial disability 
            is February 18, 1987.  Two doctors have expressed an opinion 
            as to the extent of claimant's permanent injury:  Flapan and 
            Wirtz.  Dr. Flapan's opinion was rendered well before 
            claimant's surgery and obviously is not an effective 
            measurement of claimant's impairment at the end of his 
            healing period.  The best evidence is the opinion of Dr. 
            Wirtz.  Claimant has established a 40 percent disability to 
            the right leg.  Under Iowa Code section 85.34(2)(o), the 
            loss of a leg is compensated during 220 weeks.  Therefore, 
            claimant is entitled to 88 weeks of permanent partial 
            disability benefits.
                 Pursuant to Iowa Code section 85.27, defendants are 
            Page  11
            required to furnish reasonable and necessary surgical and 
            medical services and supplies.  The record indicates that 
            defendants authorized Dr. Dolan's services in terms of 
            therapy for claimant's leg, but not as to his digestive 
            problems.  Even though claimant had a history of ulcer, the 
            only medical evidence in the record as to whether the ulcer 
            and depression claimant suffered following his work injury 
            are causally related to that injury comes from Dr. Dolan.  
            Dr. Dolan specified that such a causal relationship did 
            exist.  This unrefuted testimony is accepted as establishing 
            that the digestive and psychological problems claimant 
            suffered following his injury arose out of and in the course 
            of employment and are causally related to the work injury.  
            They are therefore compensable.  Claimant shall be awarded 
            Dr. Dolan's unreimbursed fees in the sum of $187.50 and the 
            unreimbursed prescription costs of $1,546.29.
                 Claimant also seeks mileage expenses of 208 miles.  
            Seventy of those miles are attributed to transportation to a 
            pharmacy.  Claimant lives in West Des Moines, Iowa.  He has 
            not shown that roundtrips of 22, 24 and 24 miles to a 
            pharmacy in such a metropolitan area is a reasonable and 
            necessary expense.  Claimant will be awarded 138 miles in 
            roundtrips to physicians and physical therapists pursuant to 
            joint exhibit 21.  Under Division of Industrial Services 
            Rule 343-8.1, mileage is reimbursable when it is incurred in 
            the course of treatment or for an examination and is payable 
            at the same mileage rate as the state of Iowa uses to 
            reimburse its employees for travel.  That is, $.21 per mile 
            or a total of $28.98.
                 The final issue to be determined is claimant's request 
            for additional surgery to remove the screws left in place 
            following his knee reconstruction.  There is a direct 
            conflict of medical opinion as to this issue.
                 Dr. Wirtz did not believe that removal of the screws 
            was advisable, although he conceded that the risk was small.  
            He did not attribute claimant's continued pain to the screws 
            because claimant did not point specifically to the screws 
            when complaining of symptoms.  Of course, claimant did not 
            point to any other area either.  Yet, Dr. Wirtz conceded on 
            cross-examination that if Dr. Kirkland administered a local 
            anesthetic over the screws which numbed that area and 
            reduced pain, "then taking the screws out would reduce the 
            pain."  He also conceded that if claimant was able to regain 
            strength in the leg, this would help claimant function 
                 Dr. Kirkland testified specifically that he injected 
            the area over the screws and this gave claimant 100 percent 
            relief of pain.  He was further of the view that relief of 
            pain had the potential to increase claimant's strength and 
            range of motion because he would be less inclined to avoid 
            using the joint.
                 Both Dr. Wirtz and Dr. Kirkland are board-certified 
            Page  12
            orthopaedic surgeons.  There is no reason to accept the 
            opinion of one over the other based on professional 
            qualifications.  Dr. Wirtz's opinion is less persuasive 
            because it was based essentially on the absence of claimant 
            pointing specifically to the area of the screws in 
            describing symptomatology.  On the other hand, Dr. Kirkland 
            based his opinion on clinical results:  injection of the 
            area over the screws relieved pain 100 percent.  Dr. Wirtz 
            conceded that if Dr. Kirkland did obtain that result, 
            removal of the screws should relieve claimant's ongoing pain 
                 The undersigned is of the view that reduction of pain 
            in and of itself is an appropriate, reasonable and necessary  
            goal for medical treatment.  After all, to hold otherwise 
            implies that medical treatment is only reasonable and 
            necessary if it benefits defendants (by reducing disability) 
            as opposed to claimant.  Also, it appears from Dr. 
            Kirkland's testimony and Dr. Wirtz's concession that 
            surgical removal of the screws is likely to improve 
            claimant's function as well as merely reduce his pain.  
            Defendants will therefore be ordered to provide further 
            medical services by way of surgical removal of the metal 
            screws now in place in claimant's femur.
                                 findings of fact
                 THEREFORE, based on the evidence presented, the 
            following ultimate facts are found:
                 1.  As stipulated, claimant sustained an injury arising 
            out of and in the course of his employment with defendant 
            employer on September 18, 1984.
                 2.  As stipulated, claimant's injury was to the right 
            leg.  Claimant has sustained an impairment to that member of 
            40 percent.
                 3.  As stipulated, claimant's rate of compensation is 
                 4.  Claimant has established that he reached a point 
            where significant improvement from his injury was not 
            anticipated on February 13, 1987.
                 5.  Dr. Dolan's billing in the sum of $187.50 was for 
            reasonable and necessary medical treatment attributable to 
            the work injury.
                 6.  Kiburz Pharmacy bills of $1,546.29 have been shown 
            to be for reasonable and necessary medical supplies required 
            by reason of the work injury.
                 7.  Claimant has established mileage expenses 
            attributable to the work injury and medical treatment of 138 
            Page  13
                 8.  Claimant has established that surgical removal of 
            metal screws in his femur is reasonable and necessary 
            medical treatment in that it is probable that such removal 
            will reduce pain and increase function in the right leg.
                                conclusions of law
                 WHEREFORE, based on the principles of law previously 
            cited, the following conclusions of law are made:
                 1.  Claimant has met his burden of proof in 
            establishing entitlement to healing period benefits from 
            September 18, 1984 through February 13, 1987.
                 2.  Claimant has met his burden of proof in 
            establishing entitlement to permanent partial disability to 
            his right leg of 40 percent by reason of his stipulated work 
            injury of September 18, 1984.
                 3.  Claimant has established his entitlement to 
            reimbursement for medical bills of Dr. Dolan in the sum of 
            $187.50, pharmaceutical expenses of $1,546.29, and mileage 
            expenses of $28.98.
                 4.  Claimant has established his entitlement to further 
            medical services and supplies necessary for surgical removal 
            of the metal screws now implanted in his right femur.
                 THEREFORE, IT IS ORDERED:
                 Defendants shall pay to claimant one hundred 
            twenty-five point five seven one (125.571) weeks of healing 
            period benefits at the stipulated rate of three hundred 
            twenty-six and 54/100 dollars ($326.54) per week totalling 
            forty-one thousand three and 95/100 dollars ($41,003.95).
                 Defendants shall pay to claimant eighty-eight (88) 
            weeks of permanent partial disability at the stipulated rate 
            of three hundred twenty-six and 54/100 dollars ($326.54) per 
            week commencing February 18, 1987 and totalling twenty-eight 
            thousand seven hundred thirty-five and 52/100 dollars 
                 Defendants shall be entitled to credit of sixty-eight 
            thousand two hundred thirty-seven and 53/100 dollars 
            ($68,237.53) for healing period and permanent partial 
            disability benefits voluntarily paid prior to hearing.
                 As all disability benefits have accrued, they shall be 
            paid in a lump sum together with statutory interest.
                 Defendants shall reimburse claimant for medical 
            expenses relating to Dr. Dolan, Kiburz Pharmacy, and mileage 
            in the sum of one thousand seven hundred sixty-two and 
            77/100 dollars ($1,762.77).  As such entitlement has 
            Page  14
            accrued, it shall be paid in a lump sum, but without 
                 Defendants shall supply appropriate medical services 
            and supplies reasonably necessary for surgical removal of 
            the metal screws now implanted in claimant's right femur and 
            shall further pay temporary total disability benefits 
            occasioned by that surgery.
                 Costs of this action shall be assessed to defendants 
            pursuant to Division of Industrial Services Rule 343-4.33.
                 Defendants shall file claim activity reports as 
            requested by this agency pursuant to Division of Industrial 
            Services Rule 343-3.1.
                 This cause shall be returned to the prehearing 
            assignment docket for further proceedings as to claimant's 
            entitlement to penalty benefits under Iowa Code section 
                 Signed and filed this ______ day of ____________, 1990.
                                          DAVID RASEY
                                          DEPUTY INDUSTRIAL COMMISSIONER
            Copies To:
            Mr. David D. Drake
            Attorney at Law
            West Towers Office Complex
            1200 35th Street, Suite 500
            W. Des Moines, Iowa  50265
            Mr. Frank T. Harrison
            Attorney at Law
            Suite 111, Terrace Center
            2700 Grand Avenue
            Des Moines, Iowa  50312
                                               1802, 2501, 2700
                                               Filed February 23, 1990
                                               DAVID RASEY
                     before the iowa industrial commissioner
            WILLIAM D. BURGDUFF,          :
                 Claimant,                :
            vs.                           :
                                          :         File No. 776776
            BILL BRADY & SONS             :
            CONSTRUCTION,                 :      A R B I T R A T I O N
                 Employer,                :         D E C I S I O N
            and                           :
                 Insurance Carrier,       :
                 Defendants.              :
            Treating physician opined that claimant reached maximum 
            medical improvement of leg in September, 1986.  However, 
            physical therapist in same office found measurable 
            improvement in both strength and endurance through last 
            appointment in February, 1987, following which claimant's 
            condition was stable or deteriorated.  Healing period held 
            to end in February, 1987.
            2501, 2700
            Following anterior cruciate reconstruction, claimant had two 
            metal screws left in femur which had no function after 
            recovery from surgery.  Most persuasive medical evidence 
            established that removal of screws would probably relieve 
            pain and increase function.  Defendants were ordered to 
            provide medical services for surgical removal of screws as 
            reasonable and necessary medical treatment.
         EDNA DUCE,
                                                     File No. 776806
         TEXTRON, INC.,
                                                       A P P E A L
                                                     D E C I S I 0 N
              Insurance Carrier,
                              STATEMENT OF THE CASE
              Defendants appeal from an arbitration decision awarding 
         claimant permanent partial disability benefits for a 25 percent 
         impairment to her left hand.
              The record on appeal consists of the transcript of the 
         arbitration hearing and defendants' exhibits A and B.  Claimant's 
         exhibit 1 is an offer of proof.  Both parties filed briefs on 
              Defendants state the following issues on appeal:
              1.  Did the deputy industrial commissioner err in 
              determining claimant sustained her burden of proof to show 
              her current complaints and disability are causally connected 
              to her work injury?
              2.  Did the deputy industrial commissioner err in awarding 
              claimant a 25% permanent partial disability of her left 
                              REVIEW OF THE EVIDENCE
              Claimant testified at the arbitration hearing that she is 59 
         years old, left-handed and that she had worked for defendant, 
         Textron, for nine years before the injury alleged in this claim. 
          At the time of her injury she states she was a light production 
              On December 26, 1982 claimant states she injured her left 
         hand while she was changing ink color in a machine which 
         packaged ink cartridges at Textron's plant.  Claimant states 
         DUCE V. TEXTRON, INC.
         Page   2
         she was removing a card from the machine when another person 
         turned on the machine; claimant's left hand became caught 
         between two bars which are operated by air pressure.  Someone 
         had to turn off the machine before she could remove her hand.  
         She estimates that her hand was caught in the machine for about 
         a minute.
              Claimant was then taken directly to the company doctor, 
         Bernard Helling, M.D., at the Valley Clinic, who cleaned, 
         stitched and x-rayed claimant's hand.  Dr. Helling also gave 
         claimant a tetanus shot.
              Claimant reported to work the following day; however, for 
         three weeks she worked in inspection which only required the 
         use of her right hand.  She continued to receive her regular 
         salary for those three weeks.  After the three weeks in 
         inspection claimant resumed her regular duties which she was 
         performing at the time of the injury.
              Claimant states she saw Dr. Helling at least twice 
         following the injury; once he removed her stitches following 
         the injury and once he x-rayed her hand and sent her to a 
         physical therapist.  Claimant states that she went to the 
         physical therapist for about two weeks and that the therapist 
         put heat packs on her hand and exercised it.  Claimant states 
         that following the physical therapy the top of her hand didn't 
         swell but her fingers continued to swell, even today.
              Claimant states that in January 1984 she was examined by 
         Bruce Sprague, M.D.  She says that this examination took no 
         more than five minutes and that Dr. Sprague took no x-rays but 
         simply tested the flexibility of movement of her fingers and of 
         her wrist.  She states that at that time some days her hand 
         DUCE V. TEXTRON, INC.
         Page   3
         felt okay and other days it did not.  She felt she could not do 
         as much work as before the injury but she admits she did do the 
         same kind of work.
              She also states she experiences difficulty with her 
         ability to grip objects with her left hand.  Some times she 
         would drop things.
              In January and February of 1985 claimant went to see 
         Donald Mackenzie, M.D.  Dr. Mackenzie examined her and 
         prescribed medications to which claimant opines she was 
         allergic.  Dr. Mackenzie also recommended that claimant see 
         William Blair, M.D., a hand specialist in Iowa City but 
         claimant did not go because she felt that she could not afford 
              At the present time claimant testified that she 
         experiences soreness and swelling in her left hand.  She also 
         experiences difficulty writing, rolling her hair, sewing and 
         performing other household chores.  She has difficulty at work 
         picking up small objects.
              Claimant discloses on cross-examination that she bid into 
         a stringing job because there were people she knew in that 
         department.  The stringing job involves working with small 
         objects such as pen cups and barrels.  Claimant admits that her 
         current performance rating is 117 percent of the minimum 
         requirement.  Claimant denies knowledge of any performance 
         rating for the job she was performing at the time of her 
              On redirect examination claimant testified that she had 
         DUCE V. TEXTRON, INC.
         Page   4
         never had any injuries or problems with her left hand prior to 
         the December 1982 accident.
              Phyllis Box, the industrial health nurse at Textron, 
         testified at the arbitration hearing that she changed 
         claimant's bandages regularly between claimant's visits to Dr. 
         Helling and gave her a tetanus shot in 1984.  She also states 
         she removed a sliver from claimant's left index finger.
              Ms. Box denies that claimant has complained to her about 
         any stiffness, pain or swelling in her left hand since she has 
         been working as a stringer.  Nor is Ms. Box aware of any 
         medical restrictions being placed on claimant's left hand.  She 
         testified that claimant missed eight hours of work in 1984 and 
         that claimant has not missed any work in 1985.  She reveals 
         that claimant's performance rates for the period of January 
         1985 through November 1985 have ranged from 112 percent to 127 
         percent and have never fallen below 100 percent.  Ms. Box 
         discloses on cross-examination that the date that claimant 
         sustained her injury was December 27, 1982 and that she saw 
         claimant the following day.  She describes claimant's hand 
         injury as a laceration.
              Defendants' exhibit A is a letter from Dr. Mackenzie to 
         claimant's attorney dated February 27, 1985.  Dr. Mackenzie 
         states the following in that letter:
                 Following our telephone conversation of February 19, this 
              is a letter about Edna Duce's lack of response to 
              conservative treatment.  We have treated her with 
              anti-inflammatory medication and the use of a putty ball 
              without improvement.  She has problems with 
              anti-inflammatory use because of rashes and sleeplessness, 
              and has been unable to tolerate either of the medications we 
              gave her.
         DUCE V. TEXTRON, INC.
         Page   5
                 Objectively she is able to demonstrate a grip strength 
              [sic] of 7 kg on the right and 6 kg on the left and these do 
              not seem to be too far apart.  I think objectively, and 
              using the AMA guides, we are unlikely to be able to come up 
              with a permanent impairment rating since she has full range 
              of motion, normal sensation and essentially normal strength. 
              one would expect the left hand to be slightly stronger than 
              the right since she is left handed, and so whilst the 
              difference in expected strength is not great this may be 
              explained by her pain.  She may be able to obtain a 
              relatively pain free state if Dr. Blair can find a suitable 
              treatment modality for her, but as I mentioned in the 
              preceding paragraph I think this is probably unlikely, and 
              on the basis of her difficulty in performing her work I 
              would estimate her to be 25% impaired on that hand.  The 
              limitations that I would place on the use of the hand would 
              be to avoid frequent, repetitive tasks, to avoid lifting in 
              excess of 5 lbs frequently, but occasionally able to lift 10 
              lbs and to avoid activities involving pronation and 
              supination repetitively, such as the use of a screwdriver or 
              ratchet wrench.
              Defendants' exhibit B is a letter to claimant's attorney 
         from Dr. Sprague dated January 25, 1984.  Following a review of 
         the relevant history of claimant's left hand injury, Dr. Sprague 
         states the following in this letter:
                 On examination today, she has full range of motion of 
              both elbows, forearms, and wrists.  She makes full fists and 
              has full circumduction of the thumb.  There is no deformity 
              involving the left hand as compared to the right.  
              Sensibility is slightly less in the median nerve 
              distribution of the left hand, and there is a totally 
              positive Tinel' sign on the left.  She, however, has good 
              motor function involving the thenar eminence and has good 
              extension and function involving the hand.  The laceration 
              on the dorsum of the hand is well healed, and there is very 
              minimal scar formation.
                 As far as the laceration of the hand is concerned, I feel 
              there is no permanent impairment involved.  She does have 
              some evidence of an early carpal tunnel syndrome, which I am 
              not sure is related is related [sic] to her injury or not.  
              This would probably be compensable to 2-3% of her hand at 
              this time.
                                  APPLICABLE LAW
              The citations of law in the arbitration decision are 
         appropriate to the issues and evidence.
              Defendants contend that claimant has failed to establish a 
         causal connection between her injury and any disability that she 
         now suffers.  The only medical reports received as evidence are 
         DUCE V. TEXTRON, INC.
         Page   6
         defendants' exhibits A and B. As already indicated, Dr. Sprague 
         opines that claimant suffers no permanent impairment as a result 
         of the laceration to her hand.  Although Dr. Mackenzie concedes 
         that he can detect no impairment of range of motion, sensation or 
         strength, he opines that based on claimant's alleged difficulty 
         in performing her job that claimant suffers 25 percent permanent 
         impairment to the hand.  Dr. Sprague's opinion is adopted.  Dr. 
         Sprague's examination took place nearer in time to claimant's 
         injury.  No deterioration of claimant's hand condition is alleged 
         to have occurred since Dr. Sprague's examination.  Dr. 
         Mackenzie's determination that claimant suffers permanent 
         impairment to her hand based on claimant's complaints of 
         difficulty in performing her job is actually an opinion of 
         industrial disability rather than functional impairment.  Nothing 
         in Dr. Mackenzie's report indicates that he is aware of the type 
         of work that claimant does.  Dr. Mackenzie was not shown to be an 
         expert on industrial disability or what other factors he used in 
         making his conclusion.  Claimant continues to work, and the 
         record indicates that she has lost no time from work due to the 
         1982 injury.  Although claimant testified that she has difficulty 
         at work picking up small objects, she admits that she voluntarily 
         bid into her current job which requires working with small 
         objects such as pen caps and barrels.  These facts lessen the 
         weight which may be accorded Dr. Mackenzie's opinion.
              Dr. Sprague also notes that claimant shows signs of early 
         carpal tunnel syndrome.  Although he gives a two to three percent 
         impairment for the carpal tunnel syndrome, he does not opine that 
         it is related to the work injury that claimant sustained on 
         December 26, 1982.
                                 FINDINGS OF FACT
              1.  Claimant sustained a laceration to her left hand on 
         December 26, 1982 when it was caught in a machine at 
         defendant-Textron's plant.
              2.  Claimant lost no time from work as a result of this 
              3.  Claimant continues to be employed with 
              4.  Claimant suffers no permanent impairment as a result of 
         the laceration to her hand.
              5.  Claimant has early carpal tunnel syndrome.
              6.  Claimant's carpal tunnel syndrome was not caused by her 
         December 261 1982 injury.
                                CONCLUSIONS OF LAW
              Claimant sustained an injury arising out of and in the 
         course of employment on December 27, 1982.
              Claimant failed to prove any permanent impairment as a 
         result of her December 26, 1982 injury.
         DUCE V. TEXTRON, INC.
         Page   7
              Claimant suffers no permanent disability as a result of that 
              WHEREFORE, the decision of the deputy is reversed.
              THEREFORE, it is ordered:
              That claimant take nothing from these proceedings.
              That defendants pay the costs of this proceeding including 
         the costs of the transcription of the hearing proceeding.
              Signed and filed this 23rd day of November, 1987.
                                               DAVID E. LINQUIST
                                               INDUSTRIAL COMMISSIONER
         Copies To:
         Mr. George E. Wright
         Attorney at Law
         607 Eighth St.
         Marquette Bldg.
         Fort Madison, Iowa 52627
         Mr. Craig A. Levien
         Mr. Larry L. Shepler
         Attorneys at Law
         600 Union Arcade Bldg.
         111 E. 3rd St.
         Davenport, Iowa 52801