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					                      PARK PLAZA ORTHOPEDIC CLINIC
105 N. 31st Avenue, Suite 102                                        801 Harmony Street, Suite 305
Omaha, NE 68131                                                      Council Bluffs, IA 51503
402-346-1111                                                         723-328-5970
FAX: 402-408-0004                                                    FAX: 712-328-5971




                                SAMPLE IME CASE
                                     Completed May 27, 2005




For confidentiality of patient and doctors involved, identifying terms have been removed.
       For the same reason, package of references and exhibits is not included.




                                 Anil K. Agarwal, M.D., F.A.C.S.
                                Board Certified Orthopedic Surgeon
                                                                           Family Practice
                                Orthopedic
                                                                           J. Paknikar, MD
                                A.K. Agarwal, MD
                                                                           Board Certified Family Physician
                                Board Certified Orthopedic Surgeon
                                Independent Medical Examiner




May 27, 2005



Thomas D. Wulff
Law Offices of White & Wulff
209 South 19th Street, Suite 300
Omaha, NE 68102-1705



Re: John Williams VS Alltel Communications, Inc.



Dear Mr. Wulff,

We appreciate the opportunity to serve you, and thank you for sending Mr. Williams to us.

As you already aware, this case is extremely complicated with 11+ surgeries, and required
extensive medical review in order for us to prepare a thorough report herein enclosed. To
recap that effort, we spent >120 hours reviewing all of the materials provided.

Our extensive review shows in the seven conclusions attached to your report, which underline
Doctors’ visits & diagnoses, pathology, and my opinion for the case. To reiterate, our review
is comprehensive and reflects reasonable clinical certainty based upon the available
information.

Please review the file, and feel free to contact me with any questions at (402) 346-1111.
Again, we thank you for your patience and understanding, and hope that we can work
together again in the near future.



Sincerely,



Anil Agarwal, M.D; F.A.C.S.
Orthopedic Surgeon
Independent Medical Examiner




   105 N 31st Avenue, Ste 102            801 Harmony Street, Ste 305    500 West Broadway, Ste 2A
   Omaha, NE 68131                       Council Bluffs, IA 51503       Council Bluffs, IA 51503
   Ph: (402) 346-1111                    Ph: (712) 328-5970             Ph: (712) 325-8888
   Fax: (402) 408-0004                   Fax: (712) 328-5971            Fax: (712) 325-8890
                                              www.parkplazaclinic.com
                                                                                                                                                                                                                                                                                            General Info
        CONCLUSION I
                                                                                                                                     TOTAL DOCTORS’ VISITS
                                                      PRE-EXISTING                                           SURGERY                             PERSONAL HABITS                                                   DATE____________________                                                 Pre-existing
        DR VISITS & DIAGNOSES
                                                      • Compression FX – lower thoracic                      • Hernia repair (1970)              • Smoke : 1 ½ to 2 ½ packs / day – 31
        PATIENT INFORMATION                             region, limitation : no more than                    • (L) knee surgery (1985)             years                                                                                                                               All Attributed (ankle)
        Re: John Williams                               35 lbs with repetition & no more                                                         • Drink : 10-15 drinks / week
        DOB : 12/31/58                                  than 65 lbs max                                                                                                                                                                                                            Not Attributed (knee)
                                                                                                                                                                                                                   ________________________
        DOI : 06/17/99                                                                                                                                                                                             A.K. AGARWAL, MD                                          Partially attributed (ankle & knee)
                                                               MMI                                      WC : 06/17/99, Williams, John, 46 years old, Alltel Communications, Inc.
                                                    1. (L) ankle : 2/5/04                                                                                                                                                                                                         MVA (8/16/02) related)
                                                    2. (R) knee : 12/2/02 –
                                                       not related to WC


Doctor                                                                                                                        Hughes, Tewes & Yeakley, MD                                                                                                                                             Hinrichs, J.J,
                                                                                                                                                                                                                                                                                                           MD

Specialist                                                                                                                          Orthopedic Surgeons                                                                                                                   St. Elizabeth
                                                                                                                                                                                                                                                                         Regional West



             • Comminuted calcaneal fracture - (L) hindfoot                       •                                                                       • (R) knee degenerative joint                 •                                                               • Patella fracture           • Unstable –
                                                                 2                                                                 11                                                                                                                   20
Diagnosis                                                                             Internal derangement – (R) knee                                                                                         (L) leg pain, post high tibial osteotomy
                                                                                                                                                                    18 28                                                                                                       32
             • Severe medial ankle and hindfoot fracture blister                  •                                                                                                                     •
                                                                                                                                   15                                                                                                                28
                                                                                      Recurrent chondromalaciac lesions – (R) knee                          disease                                           Subtalar fusion w/ painful hardware                         – (R)                        (R) knee
                                                                                                                                                          • Status post high tibial osteotomy                                                                           • Joint effusion –
                     2
                                                                                  •                                                                                                                     •
                                                                                                    18                                                                                                                                                        30
               – (L)                                                                  (R) knee pain                                                                                                           Nonunion, subtalar joint arthrodesis – (L) foot
                                                                                                                                                              28                                                                                                                    32
             • Medial foot wound
                                  4
                                                                                  •                                                                                                                     •
                                                                                                               18                                                                                                                                 31
                                                                                      (R) knee varus deformity                                                                                                Internal derangement – (L) ankle                            (R) knee
             • Post operative – (L) ankle
                                          11
                                                                                  •   (R) knee effusion
                                                                                                        18
                                                                                                                                                                                                                                                                        • Eyelid & cheek
                                                                                                                                                                                                                                                                                     32
                                                                                                                                                                                                                                                                          laceration


                         1                                                5                                                                                                        24                                                     31                                           33
Visit          6/17/99                7/13/99             11/22/99                     10/2/00 – OP                 6/11/01- OP                1/23/02                  5/14/02                    8/21/02 –                   12/23/02                10/9/03              3/15/01                        6/6/01
                                                                                                  12                          15
                                                                                        (Yeakley)                   (Yeakley)                                                                   following MVA
                                                                      6                                                                                                            25
             6/19/99 – OP             7/22/99              1/10/00                                                                           2/5/02 – OP                5/24/02                     8/16/02                     12/26/02               11/3/03            8/16/02 – ER -                11/20/01
                        2                                                                          13                              16                 19                                                                                                                              32
             – (Hughes)                                                                  10/9/00                     6/18/01                  (Tewes)                                                                                                                     MVA – DIS
                                                4                                                                                                                                  26                        34
                                      8/12/99            1/26/00 – OP                                                                                                   5/31/02                   9/18/02                     4/3/03 – OP            12/4/03 – OP                                          1/31/02
                                                                    7                                                                                                                                                                   34                     37
                6/23/99                                   (Hughes)                       10/23/00                         7/2/01               2/13/02                                                                        (Hughes)                (Tewes)
                                      9/9/99 –                                                                                                                        6/5/02 – OP                  10/16/02
                                                                                                                                                         20                    27
                6/28/99               Wo Res                2/9/00                       11/13/00                         7/5/01              2/20/02                  (Tewes)                                                  4/16/03                12/8/03
                                                                                                                                                                                                                  35
                                                                                                                                                                                                11/1/02 – OP
                                                                      8                                                                                                            28
             6/30/99 – OP             9/16/99              3/10/00                        12/4/00                         8/1/01                3/1/02                  6/25/02                                                 5/14/03                 1/8/04
                        3
              (Hughes)                                                                                                                                                                             11/7/02
                                                                      9                                                            17                    21
                                      10/25/99             4/12/00                       12/12/00                    8/22/01                  3/12/02                7/18/02 – OP                                                7/9/03                1/14/04
                                                                                                                                                                               29
                7/01/99                                                                                                                                               (Tewes)                      12/2/02
                                                                     10                            14                                                    22                                                                              36
                                      11/2/99              6/7/00                        2/13/01                          9/20/01             3/19/02                                                                           8/1/03                  2/5/04
                                                                                                                                                                                                             30
                7/12/99                                                                                                                                                  7/25/02                  12/09/02
                                                                     11                                                             18                   23
                                      11/10/99             7/20/00                        5/9/01                     11/14/01                 4/16/02                                                                           9/10/03                 3/9/04



             • CT – (L) ankle                                                 • MRI – (L) ankle                                                   • MRI – (R) knee                                                     • CT – (L) foot
                               1                                                                        10                                                              11                                                               30
Invest
             • X-rays – (L) ankle                                                                                                                 • X-ray – leg                                                        • X-rays – (L) foot
                                  5   6 8 9                                                                                                                     20 21   22 26 28                                                           31

                                                                              • X-ray – (R) knee
                                                                                                         11 23 24 25 34




             • OP – calcaneal fracture & fracture blister – (L)               •                                                                   •                                                                    • OP – Revision arthrodesis subtalar joint (L)     • FCE                      • Medication
                                                                                                                          7                                                             12 15                                                                                     33
Rx                                                                                OP - Arthroscopy – (L) ankle                                        OP – arthroscopy – (R) knee
                        2                                                                                                                                                                                                34
                                                                              •                                                                   •                                                                                                                       • Medication
                                                                                                                          7                                                14 17 28 34 36
               hindfoot                                                           OP – removal – hardware – (L) calcaneus                             Injection – (R) knee
             • OP – calcaneal fracture & medical heel – (L)                                                                                                                                                            • Ankle arthroscopy
                                                               3                                                                                                                                                                                34
                                                                              •                                                                   •
                                                                                                                 7                                                                              19
                                                                                  OP – calcaneal ostectomy – (L)                                      OP – (R) leg – high tibial osteotomy
             • Medication                                                     •   OP – Removal hardware – (L) calcaneus
                                                                                                                         29
                                                                                                                                                  •   OP – (R) knee – arthroscopy
                                                                                                                                                                                       19 35 37

             • OP – Subtalar arthrodesis – (L) foot
                                                    7
                                                                              •                                                                   •
                                                                                     13 16                                                                                                         27
                                                                                  PT                                                                  OP – Removal external fixator – (R) leg
                                                                                                                                                  •
                                                                                                                                                          13 16
                                                                                                                                                      PT
CONCLUSION II - ANKLE
                                                       (L) FOOT / ANKLE (WC)
DR VISITS & DIAGNOSES                                    DATE____________________                                                      General Info
PATIENT INFORMATION
Re: John Williams                                                                                                                      Pre-existing
DOB : 12/31/58
                                                         ________________________                                                All Attributed (ankle)
DOI : 06/17/99                                           A.K. AGARWAL, MD
                                                                                                                                 Not Attributed (knee)

PRE-EXISTING                              SURGERY                PERSONAL HABITS                                        Partially attributed (ankle & knee)
• Compression FX – lower thoracic         • Hernia repair        • Smoke : 1 ½ to 2 ½
  region, limitation : no more than         (1970)                 packs / day – 31 years                                       MVA (8/16/02) related)
  35 lbs with repetition & no more        • (L) knee surgery     • Drink : 10-15 drinks /
  than 65 lbs max                           (1985)                 week



                          MMI                            WC : 06/17/99, Williams, John, 46 years old, Alltel Communications, Inc.
             2/5/04 – Dr. Hughes (agreed
                   by Dr. Agarwal)



Doctor                                                  Hughes, Tewes & Yeakley, MD


Specialist                                                  Orthopedic Surgeon




               • Comminuted calcaneal fracture - (L) hindfoot                  • (L) leg pain, post high tibial osteotomy
                                                                                                                                20
Diagnosis
                 2
                                                                               • Subtalar fusion w/ painful hardware
                                                                                                                       28

               • Severe medial ankle and hindfoot fracture                     • Nonunion, subtalar joint arthrodesis – (L) foot
                               2                                                   30
                 blister – (L)
               • Medial foot wound
                                    4
                                                                               • Internal derangement – (L) ankle
                                                                                                                        31

               • Post operative – (L) ankle
                                            11




                           1                                               6                            13                            30
Visit            6/17/99                  7/22/99                1/10/00                      10/9/00                   12/09/02
                                                   4                                                                                  31
               6/19/99 – OP              8/12/99               1/26/00 – OP                   10/23/00                  12/23/02
                          2                                               7
               – (Hughes)                                       (Hughes)
                                        9/9/99 - Wo                                           11/13/00              4/3/03 – OP
                                                                                                                              34
                  6/23/99                   Res                   2/9/00                                            (Hughes)
                                                                                               12/4/00
                                                                           8
                  6/28/99                 9/16/99                3/10/00                                                 4/16/03
                                                                                              12/12/00
                                                                           9
               6/30/99 – OP              10/25/99                4/12/00                                                 5/14/03
                          3                                                                             20
                (Hughes)                                                                      2/20/02
                                                                          10
                                          11/2/99                6/7/00                                                      7/9/03
                                                                                                        28
                  7/01/99                                                                     6/25/02
                                                                           11
                                         11/10/99               7/20/00                                                  10/9/03
                  7/12/99                                                                   7/18/02 – OP
                                                    5                                                 29
                                        11/22/99               10/2/00 – OP                  (Tewes)                         1/8/04
                                                                          12
                  7/13/99                                       (Yeakley)
                                                                                               7/25/02                       2/5/04



               • CT – (L) ankle                                                • CT – (L) foot
                                 1                                                              30
Invest
               • X-rays – (L) ankle                                            • X-rays – (L) foot
                                    5   6 8 9                                                      31

               • MRI – (L) ankle
                                 10




               • OP – calcaneal fracture & fracture blister – (L)              •
                                                                                                                    7
Rx                                                                                 OP – calcaneal ostectomy – (L)
                          2
                                                                               •
                                                                                      13 16
                 hindfoot                                                          PT
               • OP – calcaneal fracture & medical heel – (L)
                                                                 3
                                                                               •
                                                                                                                             29
                                                                                   OP – Removal hardware – (L) calcaneus
               • Medication                                                    •   OP – Revision arthrodesis subtalar joint (L)
                                                                                                                                34

               • OP – Subtalar arthrodesis – (L) foot
                                                      7

               • OP - Arthroscopy – (L) ankle
                                              7

               • OP – removal – hardware – (L) calcaneus
                                                             7
   CONCLUSION III - KNEE
                                                       (R) KNEE ARTHRITIS / MVA (NOT RELATED TO WC)
   DR VISITS & DIAGNOSES                                                        DATE____________________                                                General Info
   PATIENT INFORMATION
   Re: John Williams                                                                                                                                    Pre-existing
   DOB : 12/31/58
                                                                                ________________________                                            All Attributed (ankle)
   DOI : 06/17/99                                                               A.K. AGARWAL, MD
                                                                                                                                                   Not Attributed (knee)

  PRE-EXISTING                                   SURGERY                         PERSONAL HABITS                                          Partially attributed (ankle & knee)
  • Compression FX – lower thoracic              • Hernia repair                 • Smoke : 1 ½ to 2 ½
    region, limitation : no more than              (1970)                          packs / day – 31 years                                          MVA (8/16/02) related)
    35 lbs with repetition & no more             • (L) knee surgery              • Drink : 10-15 drinks /
    than 65 lbs max                                (1985)                          week


                   MMI                                            WC : 06/17/99, Williams, John, 46 years old, Alltel Communications, Inc.
   1. 12/2/02 – Dr. Tewes (agreed
      by Dr. Agarwal)
   2. 3/9/04 – Dr. Tewes


Doctor                                                Tewes & Yeakley, MD                                                                                        Hinrichs, J.J,
                                                                                                                                                                      MD

Specialist                                            Orthopedic Surgeon                                                     St. Elizabeth Regional
                                                                                                                                      West



             • Internal derangement – (R) knee                       • (R) knee effusion                                     • Patella fracture – (R)          • Unstable –
                                                             11                                   18
Diagnosis
                                                                                                                               32
             • Recurrent chondromalaciac lesions                     • (R) knee degenerative joint disease                                                       (R) knee
                                                                                                                             • Joint effusion – (R)
                           15                                           18 28
               – (R) knee
                                                                                                                                     32
             • (R) knee pain                                         • Status post high tibial osteotomy
                              18                                                                                        28
                                                                                                                               knee
             • (R) knee varus deformity
                                        18
                                                                                                                             • Eyelid & cheek
                                                                                                                                          32
                                                                                                                               laceration



                             11                                                    23                                                         33
Visit             7/20/00                      7/2/01                    4/16/02                          11/7/02                   3/15/01                          6/6/01
                                                                                   24
                 10/2/00 – OP                  7/5/01                    5/14/02                          12/2/02            8/16/02 – ER - MVA –                  11/20/01
                            12                                                                                                           32
                  (Yeakley)                                                                                                          DIS
                                                                                   25
                                               8/1/01                    5/24/02                          12/26/02                                                  1/31/02
                             13
                  10/9/00
                                                        17                         26                              36
                                             8/22/01                     5/31/02                          8/1/03
                   10/23/00
                                              9/20/01                  6/5/02 – OP                        9/10/03
                                                                                27
                   11/13/00                                             (Tewes)
                                                         18
                                            11/14/01                                                      11/3/03
                                                                                   28
                   12/4/00                                               6/25/02
                                              1/23/02                                                   12/4/03 – OP
                                                                                                                  37
                   12/12/00                                               7/25/02                        (Tewes)
                                           2/5/02 – OP
                             14                     19
                  2/13/01                   (Tewes)                      8/21/02 –                        12/8/03
                                                                      following MVA
                    5/9/01                    2/13/02                     8/16/02                         1/14/04
                                                                                   34
                 6/11/01- OP                   3/1/02                    9/18/02                           3/9/04
                           15
                 (Yeakley)
                                                        21
                                             3/12/02                     10/16/02
                             16
                  6/18/01
                                                        22                              35
                                             3/19/02                 11/1/02 – OP



             • X-ray – (R) knee                                    • MRI – (R) knee
                                     11 23 24 25 34                                          11
Invest
                                                                   • X-ray – leg
                                                                                 20 21       22 26 28




             •                                                                                                               • FCE                             • Medication
                                                      12 15                                                                         33
Rx                OP – arthroscopy – (R) knee
             •                                                                                                               • Medication
                                       14 17 28 34 36
                  Injection – (R) knee
             •
                                                            19
                  OP – (R) leg – high tibial osteotomy
             •
                                                   19 35 37
                  OP – (R) knee – arthroscopy
             •
                                                               27
                  OP – Removal external fixator – (R) leg
             •
                      13 16
                  PT
CONCLUSION IV – (L) ANKLE - PATHOLOGY                      DATE____________________                         General Info
DR VISITS & DIAGNOSES                                                                                       Pre-existing
PATIENT INFORMATION
Re: John Williams                                          ________________________                     All Attributed (ankle)
DOB : 12/31/58                                             A.K. AGARWAL, MD
                                                                                                        Not Attributed (knee)
DOI : 06/17/99




                      (L) CALCANEAL FRACTURE & (L) ANKLE PROBLEM

         Date                       Post Operative                                  Operation Procedure
6/19/1999              • Comminuted calcaneal fracture – (L)       • Closed reduction w/ manipulation & splinting,
Keith P Hughes, MD       hindfoot                                    calcaneus fracture – (L) hindfoot
                       • Severe medial ankle & hindfoot            • Deroofing & debridement of fracture blister – (L)
                         fracture blister – (L)                      medial hindfoot
6/30/1999              • Interarticular calcaneus fracture – (L)   • Open reduction & internal fixation – (L) calcaneus
Keith P Hughes, MD       foot                                        fracture
                       • Medial hindfoot skin & soft tissue        • Irrigation & debridement (deep) medial heel wound
                         necrosis post calcaneus fracture –          – (L) foot/ankle
                         (L) lower extremity
1/26/2000              • Subtalar arthrosis – (L) foot             • Subtalar arthrodesis – (L) foot
Keith P Hughes, MD     • Lateral calcaneal impingement – (L)       • Ankle arthroscopy with synovectomy – (L) ankle
                          lower extremity                          • Removal of retained hardware – (L) calcaneus
                       • Synovitis/impingement – (L) ankle         • Calcaneal ostectomy – (L)
                       • Retained hardware – (L) calcaneus
7/18/2002              • Painful retained hardware – (L)           • Removal of painful retained hardware – (L)
Douglas P Tewes, MD      calcaneus following talocalcaneal           calcaneous
                         fusion
4/3/03                 • Nounion subtalar joint (L)                • Revision arthrodesis subtalar joint (L)
Hughes, MD             • Anterior ankle impingement/synovitis      • Anterior ankle arthrotomy with partial
                         (L)                                         synovectomy/debridement (L)
CONCLUSION V – (R) KNEE - PATHOLOGY
                                                                      DATE____________________                          General Info
DR VISITS & DIAGNOSES
PATIENT INFORMATION                                                                                                       Opinion
Re: John Williams                                                     ________________________
DOB : 12/31/58                                                        A.K. AGARWAL, MD                              All Attributed (ankle)
DOI : 06/17/99                                                                                                      Not Attributed (knee)




                                             (R) KNEE ARTHRITIS / MVA
    Date                Post Operative                     Operation Procedure                                 Finding
                                                                                                         Etiology/Remarks
10/2/2000      • Internal derangement (R) knee       • Arthroscopy – partial medial         1. Pre-existing
John C.        • Torn medical meniscus                 menisectomy and debriment            2. Degenerative process
Yeakley, MD    • Chondromalacia Grade III medial       chondromalacia medial femoral        3. All physicians/surgeons fully agreed –
                 femoral condyle                       condyle                                  degenerative process (R) knee
6/11/2001      • Grade III and IV chondromalacia     • Arthroscopy – debriment of           4. Bow legged – medial meniscus torn
John C.          changes                               chondromalacia and                   5. MRI – 8/25/00
Yeakley, MD    • Recurrent tear – remaining            microfracture of grade IV lesions,       • Degenerative tear medial meniscus
                 portion of medial meniscus            redebriment of torn portion of           • Degenerative bony change
                                                       medial meniscus                      6. Op report :
2/5/2002       • (R) knee medial compartment         • (R) leg high tibial osteotomy            • Degenerative type tear medial
Douglas          arthrosis with medial meniscus      • (R) knee arthroscopy partial               meniscus
Tewes, MD        tear                                  medial meniscectomy                      • Significant grade III chondromalacia
               • (R) leg varus alignment             • (R) leg application of external            medial femoral condyle
                                                       fixator uniplanar                    7. MVA 8/16/02 – has a fractures (R)
6/5/2002       • Retained external fixator (R) leg   • Removal of external fixator (R)          patella, and subsequent residual
Douglas                                                 leg, under anesthesia                   problems
Tewes, MD                                                                                   8. Did not complain for (R) knee, any
12/4/03        • (R) knee chondral loose bodies,     • (R) knee arthroscopic removal of         symptoms, on 7/20/03
Douglas          multiple                              multiple loose bodies                9. Smoking 1 ½ to 2 ½ packs/day –
                                                                                                affects degenerative changes in knee
Tewes, MD      • (R) knee medium compartment
                                                                                            10. (L) knee surgery (1985) – arthroscopy
                 degenerative arthrosis
                                                                                                – synovial shelf
               • (R) knee patellar
                                                                                            11. Directly or indirectly not involved (R)
                 chondromalacia
                                                                                                knee on accident 6/17/99
11/1/02        • (R) knee chondromalacia of the      • (R) knee arthroscopic                MVA (8/16/02) related
Douglas          patella and trochlea                  examination and chondroplasty
Tewes, MD                                              of the patella and trochlea
                                 PRE-EXISTING                            SURGERY                            PERSONAL HABITS
CONCLUSION VI – OPINION          • Compression FX – lower thoracic       • Hernia repair (1970)             • Smoke : 1 ½ to 2 ½ packs / day – 31              DATE____________________
PATIENT INFORMATION                region, limitation : no more than     • (L) knee surgery (1985)            years
                                   35 lbs with repetition & no more                                         • Drink : 10-15 drinks / week
Re: John Williams                  than 65 lbs max
DOB : 12/31/58                                                                                                                                                 ________________________
DOI : 06/17/99                                                                                                                                                 A.K. AGARWAL, MD
                                                                     A.K. Agarwal, Orthopedic Surgeon
                                                                                 OPINION

                          Comminuted calcaneal fracture –                    • Fell 6 ‘ on rock and sustained comminuted              •   He did not see doctor since 1.25 years
     Diagnoses            (L) hindfoot, Ankle synovitis (L)                    fracture (L) calcaneal                                 •   Best to go back to work ASAP
                                                               A                                                                      •   Home exercises
                                                                                                                                      •   Over the counter medication, not narcotics
                                                                                                                                      •   (R) knee maybe follow up with physician (not
                          Degenerative process (R) knee,                                                                          A       WC injury)
                          torn medical meniscus, Fx Patella,
   Other Diagnoses        chondromalacia Grade III medial
    (not related to       femoral condyle, (R) leg varus                     • He has degenerative process on (R) knee and                                                                F
       the WC)            alignment, old compression fracture                  also involved in MVA on 8/16/02.
                          thoracic spine, addiction to                       • He had a compression fracture in the lower
                          narcotics                          B                 thoracic region and had a functional lifting of        • Dr. -------- confirmed MMI on 2/5/04 for (L)
                                                                               no more than 35 lbs with repetition and no               ankle & foot
                                                                               more than 65 lbs maximum                               • Dr. ------- confirmed MMI on 2 occassions for
                          (L) ankle : fair – good (confirmed by              • No direct or indirect relationship to WC injury          (R) knee, 12/2/02 and 3/9/04 (Dr. Agarwal
      Prognosis           Dr. ---------, 2/5/04)                             • He had no complaint for (R) knee until July 20,          agrees with 12/2/02)                          G
                          (R) knee : good (confirmed by Dr. --                 2000
                          -----, 12/26/02                      C
                                                                             • Refer to Conclusion V
                                                                                                                                      • For (L) ankle, no specific limitation or
                                                                                                                                  B     restriction placed. Recommended by Dr. ------
       Etiology           Fell from ladder (WC)                D                                                                        ----- on 2/5/04.
                                                                                                                                      • (R) knee has arthritis process, very difficult to
                                                                                                                                        lift, bend, walk, and go up & down stairs, but
    Investigation         No more investigation                E                                                                        this has nothing to do with WC
                                                                                                                                      • He can lift 30 lbs, limited walking and standing
                          (L) Ankle : satisfied                                                                                   C                                                       H
      Treatment           (R) Knee : may need follow-up        F
                          occasionally
                                                                             • All investigation and surgeries for (R) knee           • See detail in Conclusion VII
                                                                               have no relationship directly or indirectly with
         MMI              Reached : (L) ankle – 2/5/04,                        WC injury
                          (R) knee – 12/2/02                   G             • For (R) knee, refer to “B”


     Work Status          He can work light to medium duty                                                                        D                                                       I
                                                               H

                                                                             • Obviously no more investigation for (L) ankle          Complex (for liability factor)
     Permanent            Yes, refer to Conclusion VII                         needed
      Disability                                               I             • All investigation for (R) knee has nothing to do
                                                                               with WC injury (6/17/99)
                                                                             • Investigation and treatment for (L) ankle
   Liability Factor       Patient did not work for 6 years!!                   maybe excessive
       (Fear)                                                  J                                                               E                                                          J


                          This case is complex (WC/pre-existing arthritis/MVA, etc), was managed aggresively, has lot of complications (Blister, non-union, etc), with liability factor
      Summary             (11+ surgeries and not working for 6 years) and possible Narcotic dependency. Every Orthopedic Surgeon has different opinion for this case, and I believe
                          each factor may play a role in this case.
                                                                                                              Color Index
CONCLUSION VII - PERMANENT DISABILITY
                                                            DATE____________________                                General Info
PATIENT INFORMATION
Re: John Williams                                                                                                   Pre-existing
DOB : 12/31/58
DOI : 06/17/99                                                                                                  All Attributed (ankle)
                                                            ________________________
                                                            A.K. AGARWAL, MD                                   Not Attributed (knee)




                   PERMANENT DISABILITY – AMA GUIDELINES 5TH EDITION
                               (L) ANKLE & FOOT --- whole body (lower extremity) [foot]
                                Dr. Agarwal                   Dr. Hughes (2/5/04)                             Contributory Factor
(L) Foot                       6%(15%)[21%]                      4%(10%)[14%]
(L) Ankle                      3%(7%)[10%]                        2%(6%)[9%]
Combined (page 604)            9%(21%)[29%]                      5%(13%)[22%]                                             WC
                                                 Using 5th edition, his calculation supposed to
                                                               be 6%(15%)[21%]


                   (R) KNEE (speculations, not related to WC) --- whole body (lower extremity)
                                Dr. Agarwal        Contibutory Factor                  Dr. Tewes              Contributory Factor
A. Patellar fracture             5%(12%)                                               2%(5%)
                                                         MVA                                                        MVA
undisplaced, healed, result                                                    note : 5% lower extremity =
                                                      DOL : 8/16/02            2% whole body                     DOL : 8/16/02
in chondromalacia
B. Meniscectomy, medial          5%(12%)
or lateral Partial +
                                                 Pre-existing (Arthritis)
chondromalacia _ patella +
Medial Femoral Condyle
Total (A+B). Proximal tibial     10%(25%)                                              20%(50%)              Pre-existing (Arthritis)
                                                                                note : 50% lower extremity
osteotomy – Good result                                                             = 20% whole body                or WC
Ultimate future (10-15           15%(37%)
                                                   MVA + Pre-Existing
years) – total knee
arthroplasty (Good result
99%)
                      PARK PLAZA ORTHOPEDIC CLINIC

                                Anil K. Agarwal, M. D.

105 N. 31st Avenue, Suite 102                                801 Harmony Street, Suite 305
Omaha, NE 68131                                              Council Bluffs, IA 51503
402-346-1111                                                 712-328-5970
FAX: 402-408-0004                                            FAX: 712-328-5971

                                      May 20, 2005




Thomas D. Wulff
Law Offices of White & Wulff
209 South 19th Street, Suite 300
Omaha, NE 68102-1705


RE:              John WILLIAMS
Vs               Alltel Communications, Inc
DOI:             06/17/99
DOB:             12/31/58


Dear Mr. Wulff:

Mr. Williams is a 46-year-old right-handed male. He came to the clinic for an
Independent Medical Examination at 12:30 P.M. on April 21, 2005. The interview was
started at 1:00 P.M. followed by a physical examination which ended at approximately
4:00 P.M. Mr. Williams was informed that this was an Independent Medical
Examination and that the report of this encounter would be sent only to the company who
had requested it.

CHIEF COMPLAINT:

    1.      Left ankle pain since June 17, 1999.
    2.      Right knee pain since July 20, 2000.

HISTORY OF INJURY:

The records indicate that Mr. Williams was at work on June 17, 1999, when he fell from
a 6’ ladder, landing on some rocks. He sustained a severe injury to his left foot.
However, over the past almost six years he has undergone:
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99



1.     06/19/99        Closed reduction with manipulation and splinting, calcaneus
                       fracture left hindfoot.

2.     06/30/99        ORIF, left calcaneal fracture, with irrigation and debridement
                       (deep) medial heel wound, left foot/ankle.

3.     01/26/00        Subtalar arthrodesis, left foot. Ankle arthroscopy with
                       synovectomy, left ankle. Removal of retained hardware, left
                       calcaneus. Calcaneal osteotomy, left.

4.     10/02/00        Arthroscopy with partial medical meniscectomy and debridement
                       of chondromalacia, medial femoral condyle, right.

5.     06/11/01        Arthroscopy with debridement of chondromalacia and micro-
                       fracture of Grade IV lesions on the medial femoral condyle and
                       redebridement of a torn portion of the medial meniscus.

6.     02/05/02        Right leg high tibial osteotomy. Right knee arthroscopy and
                       partial medial meniscectomy. Right leg application of external
                       fixator uniplaner.

7.     06/05/02        Removal of external fixator, right leg, under anesthesia.

8.     07/18/02        Removal of painful retained hardware from left calcaneus.

9.     11/01/02        Arthroscopy right knee and debridement (MVA).

10.    04/03/03        Revision arthrodesis subtalar joint, left.
                       Anterior ankle arthrotomy with partial synovectomy/
                       debridement, left.

11.    12/04/03        Arthroscopy, knee. (WC)

All surgeries were done by doctors at the Lincoln Orthopedic Center, P.C., either by Dr. -
-------, Dr. -------- or Dr. --------.

Then, on August 16, 2002, he was involved in a motor vehicle accident when his vehicle
was hit on the rear panel, his car was spun around and ran into a Pepsi truck. He had
complaints of pain along the right knee and pain in the left chest wall area. From this
accident he had a right knee patella fracture, right knee hemarthrosis, left chest wall pain
and a left chest wall contusion. He was to have a hinged range of motion knee brace, 0 to
30°. He was to continue crutches for three weeks. He was to continue straight leg raises
and quadriceps sets.


                                                                                          2
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99



PAST MEDICAL HISTORY:
Medical:    He had a compression fracture in the lower thoracic region and has a
            functional lifting limitation of no more than 35 lbs with repetition and
            no more than 65 lbs maximum. He reports arthritis and back problems.
            He had a back injury in approximately 1990.
Allergies:  No allergies reported.
Medication: None.
Surgeries:  Hernia surgery 1970; left knee surgery in approximately 1985.
Personal:   He has smoked 1 ½ packs of cigarettes a day for 31 years. He has two or
            three alcoholic beverages a day, or about 10 to 15 drinks a week. He has
            had three years of college and is married.

PAST/PRESENT TREATMENT:
Total medical office visits: 100+ visits.
Last medical office visit: January of 2004 with Dr. --------.

WORK HISTORY:

Mr. Williams is not working. The last time he worked on was on June 17, 1999. He was
working in industrial production, mostly. The job duty was wiring phone systems. The
patient had been employed by Alltel since 1995.

REVIEW OF MEDICAL RECORDS:

-------- Orthopedic Center – Drs. -------- and--------

06/17/99       Dr. -------- reports he has seen a man with a displaced comminuted intra-
               articular joint depression type fracture of the left calcaneus sustained in a
               fall from a height earlier this afternoon. Mr. Williams was first seen in the
               --------- Clinic by David --------, M.D., and was referred directly to our
               clinic for evaluation. On examination there is moderate swelling around
               the calcaneus with bruising. He was placed in a well padded compression
               dressing and posterior splint, and is referred to the hospital for admission
               for elevation, icing and pain control. A CT scan was planned and
               consultation with Dr. -------- -------- is to be obtained, as he is a foot and
               ankle specialist.

06/19/99       Surgeon’s Operative Record
               Surgeon: -------- --------, M.D.
               Assistant: J. C. --------, M.D.
               Pre & Postop DX:
               1.     Comminuted calcaneal fracture, left hindfoot.
               2.     Severe medial ankle and hindfoot fracture blister, left.


                                                                                           3
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99



             Procedure:
             1.    Closed reduction with manipulation and splinting, calcaneus
                   fracture, left hindfoot.
             2.    Deroofing and debridement of fracture blister, left medial hindfoot.

06/23/99     Four days following surgery the patient was seen for follow-up. He
             denied complaints at this visit. There was moderate drainage of the
             fracture blister, but no new areas of blister. Overall swelling in the foot
             and ankle has improved.
             Impression: Left calcaneus fracture with blister development.
             Patient is scheduled for surgery June 30, 1999. Mr. Williams is to report
             prior to the surgical procedure for follow-up and evaluation. A Cam
             walker was prescribed and we fit the patient with a Don Joy size medium
             CAM walker.

06/28/99     The patient returned for follow-up evaluation. Examination reveals
             improvement in the fracture blister, although distally just inferior to the
             medial malleolus there is a small area of eschar. Patient is scheduled for
             an ORIF of the calcaneus, given improvement of the wound. At the time
             of surgery the medial eschar will be debrided.

06/30/99     Surgeon’s Operative Record
             Surgeon: -------- P. --------, M.D.
             Pre & Postop DX:
             1.     Interarticular calcaneus fracture, left foot.
             2.     Medial hindfoot skin and soft tissue necrosis post calcaneus
                    fracture, left lower extremity.
             Procedure:
             1.     Open reduction and internal fixation, left calcaneus fracture.
             2.     Irrigation and debridement (deep) medial heel wound, left foot/
                    ankle.

             Physicians First Certificate (to be signed by attending physician).
             This notes the date of injury, nature of injury. Patient had surgery 06/19/99
             and 06/30/99. Will be off work for some time. This was returned to
             Employees Disability Benefits and Death Benefits, --------.

07/01/99     Collapsible wheelchair prescribed.

07/12/99     Physician’s First Certificate states the patient was seen 06/28/99, there
             was no evidence of any cause other than the accident as described above.
             The patient was not able to return to work and would next be seen on July
             13, 1999.


                                                                                           4
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99



07/13/99     The patient was seen in the office for follow-up of Cam walker instep
             straps due to bulky bandages.

             Office notes this date indicate the patient has no complaints with the
             exception of some difficulty sleeping. The cast was removed and the
             staples in the lateral aspect wee removed. The patient was given a refill of
             his Ambien, to use p.r.n., along with Keflex for five days. He is to initiate
             wet and dry dressings as well as the CAM walker in one position and non-
             weightbearing.

07/22/99     Mr. Williams has been undergoing twice a day dressing changes as well as
             CAM walker immobilization. He remains non-weightbearing since
             surgery. He reports continued difficulty with sleep and moderate pain.
             There is excellent granulation of the medial open wound without evidence
             of purulent drainage or cellulitis. The patient is to continue dressing
             changes daily on the medial wound and also remain non-weightbearing.
             Antibiotics were discontinued today and he was given a refill of Nicodin,
             Ambien and Volaren. There would be no further refills of Vicodin or
             narcotic medication.

08/12/99     The patient is now six weeks postop and denies specific complaints. Two
             x-rays of the calcaneus reveal overall satisfactory reduction of the subtalar
             joint with no change in position of the hardware. He is to begin
             progressive partial weightbearing over the next month.
             Impression:
             1.      Status post open reduction internal fixation calcaneus fracture.
             2.      Status post wound care management medial foot wound.

09/09/99     Patient reports he is progressing well but still is utilizing the Cam walker
             about half the day. He also is using crutches. His work restrictions will
             be continued, with one hour per day standing and use of crutches for the
             next two or three weeks. Expect maximal medical improvement in
             approximately two to three months.

09/16/99     Physician’s Supplemental Certificate:
             Diagnosis: Interarticular calcaneus fracture, left foot, medial hindfoot skin
             and soft tissue necrosis post calcaneus fracture, left lower extremity.
             There are no complications and the prognosis is good. The patient can
             return to work on September 9, 1999, light duty, only standing one
             hour per day. Must use crutches until further notice. Employee will
             require further treatment and has a follow-up appointment on l0/21/99.




                                                                                            5
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99



10/25/99     Mr. Williams reports he has been slowly improving regarding ambulation
             ability. He can tolerate approximately three days of 8-10 hours of
             standing and walking. He reports some pain along the anterior ankle joint
             line with stair climbing, especially going down stairs. At this point the
             patient will progress activities with normal shoe wear with bilateral
             custom molded orthotics as recommended. He is restricted 10 lb. lifting,
             no standing greater than one to two hours per day and limited walking to a
             total of five blocks a day.

11/02/99     Patient seen to make impressions for foot orthotics to fabricate pelite and
             cork inserts. Fit when fabricated.

11/10/99     Patient seen for fitting and delivery of inserts.

11/22/99     There is some pain in the subtalar joint when walking on uneven surfaces
             and with prolonged ambulation. There is pain across the anterior ankle
             jointline with prolonged ambulation, as well as some continued range of
             motion difficulties.

             X-rays, AP, lateral and oblique views of the ankle and hindfoot reveal a
             well healed calcaneus fracture. The subtalar joint shows minimal arthrosis
             posteriorly. Overall position of the screws appear satisfactory. The ankle
             joint appears normal, without evidence of osteochondral defect or other
             significant obvious abnormalities.
             Impression:
                 1. Status post open reduction, internal fixation, calcaneus
                     fracture, left ankle.
                 2. Residual stiffness, ankle and subtalar joint.
             The patient will initiate physical therapy modalities for aggressive range
             of motion strengthening. He will continue the custom molded orthotics as
             well as current work restrictions.

01/10/00     Mr. Williams reports continued anterior ankle pain and swelling, as well
             as significant lateral distal fibular and subtalar pain. He has the most
             difficulties with uneven surfaces or walking without shoes. He has
             primary pain with weightbearing ambulation. He discontinued physical
             therapy because he felt he had plateaued with this. There has been no
             significant improvement over the last two months.

             X-RAYS:
             1. Three views of the ankle reveal no significant changes ankle with
                no evidence of changes in the talar bony structure, any



                                                                                           6
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99



             2. shift of the talus in the ankle mortise or significant degenerative
                changes of the ankle.
             2.     Broden’s view of the subtalar joint shows the hardware is not
                    crossing the joint. The hardware appears stable. There is
                    some increased width of the calcaneus visualized on Harris
                    view with slight lateral displacement of the tuberosity
                    fragment.
             3.     There does appear to be possible impingement of the superior
                    hardware into the fibula and possibly impintgement of the
                    prominent lateral calcaneal wall into the fibula with
                    weightbearing.

             Impressions:
             1.      Status post open reduction internal fixation calcaneus fracture,
                     left lower extremity.
             2.      Status post open irrigation debridement with secondary wound
                     closure of medial open wound, left hindfoot.
             3.      Continued subtalar joint pain with weightbearing with possible
                     subtalar arthrois, left hindfoot.
             4.      Painful symptomatic retained hardware, lateral calcaneus,
                     with lateral impingment, left hindfoot.
             Options were discussed and the patient elected to proceed with removal of
             the hardware and lateral calcaneal exostectomy/osteotomy. He also
             elected to proceed with arthroscopic evaluation of the ankle.

01/26/00     Surgeon’s Operative Record
             Surgeon: -------- P. --------, M.D.
             Pre & Postop DX:
             1.     Subtalar arthrosis, left hindfoot.
             2.     Lateral calcaneal impingement, left lower extremity.
             3.     Synovitis/impingement, left ankle.
             4.     Retained hardware, left calcaneus.
             Procedure:
             1.     Subtalar arthrodesis, left foot.
             2.     Ankle arthroscopy with synovectomy, left ankle.
             3.     Removal of retained hardware, left calcaneus.
             4.     Calcaneal ostectomy, left.

02/09/00     Today Mr. Williams has no specific complaints. On examination there is
             moderate swelling laterally. There is mild drainage at the corner of the
             incision without evidence of significant erythema. The patient will
             continue non-weightbearing. He was placed in a short leg cast. The
             patient is unable to work until his next evaluation.


                                                                                        7
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99



03/10/00     Patient has been non-weightbearing for the last six weeks. The
             examination is satisfactory.
             X-rays, two views of the hindfoot, reveal satisfactory overall alignment.
             Arthrodesis site is consolidating. Screw position appears satisfactory.
              He will progress weightbearing 25-50-75 percent each week-and-a-half.

04/12/00     Patient has continued pain on the posterior aspect of his heel in the area of
             the screw insertion and continued pain anteriorly at the ankle joint level.
             Now 100 percent weightbearing. He does not like o use the Cam walker
             boot because it makes his foot more painful.
             X-rays: AP and lateral views of the calcaneus and AP and lateral views of
             the ankle show the arthrodesis site appears solid with no evidence of screw
             loosening or motion. There does not appear to be calcaneal fibular
             impingement.
             Physical therapy to be initiated for active range of motion of the ankle and
             progressive weight bearing as tolerated. As of 04/13/00 patient was to
             work light duty with no stnding, sitting only with elevation of 2 to 3
             degrees.

06/07/00     Today the patient’s primary complaint is pain along the posterolateral heel
             and over the anterior aspect of the ankle, similar to the pain he had prior to
             ankle arthroscopy. On examination there was mild tenderness along the
             posterolateral heel in the area of the screwhead.
             Impression:
             1.     Status post subtalar arthrodesis post calcaneus fracture, left.
             2.     Painful retained hardware, left hindfoot.
             3.     Continued anterior ankle pain, left.
             With a normal arthroscopy but continued pain, consideration was given
             for an MRI scan of the left ankle. The subtalar arthrodesis is progressing
             as predicted. We will consider screw removal at a nine month standpoint.
             Therapy will be continued and work hardening will be initiated.

             The patient could to light duty work with standing 1 to 2 hours , but
             primarily sitting duties.

06/19/00     The MRI was reviewed and in a telephone conversation the patient was
             told to initiate a work hardening program.

07/20/00     He complains of decreased dorsiflexion of the ankle and some continued
             anterior ankle pain. His primary complaint today is right knee pain
             along the medial aspect of the joint line. He has difficulty with spotting
             and ladder climbing due to the continued pain. This has been present
             since the initial postoperative calcaneal fracture recovery.


                                                                                          8
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99



             McMurray’s test is significantly positive along the medial joint line with
             significant pain with internal and external rotation of the tibia.
             X-rays, AP, lateral and oblique of the right knee who no evidence of
             obvious bony or structural abnormalities.
             Impression:
             1.      Internal derangement, right knee.
             2.      Status post subtalar arthrodesis, post calcaneus fracture, left.
             3.      Residual ankle joint stiffness, decreased dorsiflexion, left.
                     An MRI was to be obtained of the right knee. Depending upon the
                     findings may consider arthroscopy. The patient’s work hardening
                     program will be discontinued pending further evaluation of the
                     knee.
                     Patient unable to work until next evaluation.

10/02/00     Operative Report – Orthopedic Surgery Center of --------
             Surgeon: ----- --------, M.D.
             Preop DX: Internal derangement of right knee – suspect torn medial
             meniscus.
             Postop DX: Internal derangement right knee with torn medial meniscus
             and chondromalacia, Grade III, medial femoral condyle.
             Procedure: Operative arthroscopy with partial medial meniscectomy and
             debridement chondromalacia medial femoral condyle.

10/09/00     The patient is getting along very well postop. Continue progressive
             exercise and rehabilitation over the next one to two weeks. Unable to
             return to work.

10/23/00     Patient getting along much better. Still having enough residual symptoms
             that Dr. -------- thinks continued physical therapy and restriction on work
             activities is warranted. Unable to work until next evaluation on November
             13, 2000.

11/13/00     Range of motion and muscle strength is better. Swelling in his knee has
             gone down and he now does most normal everyday activities without
             difficulty. If he is doing well in three weeks, he will probably be
             dismissed from the clinic. Unable to work until next evaluation on
             December 4, 2000.

12/04/00     The patient appears now to be recovered sufficiently to allow normal
             physical activities. He is in the process of having his foot and ankle on the
             left evaluated for permanent disability and does not currently have a job
             available to him. Dr. -------- will see him on a p.r.n. basis. Dr. -------- will
             continue care and follow-up for the foot and ankle injury on the left.


                                                                                           9
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99



             Unable to work until next evaluation on 12/12/00.

             Dr. -------- does write a note that Mr. Williams can return to regular duties
             for the right knee only, this date.

12/12/00     Mr. Williams reports some continued mild ankle pain and stiffness with no
             significant pain along the heel area with the exception of occasional
             morning heel pain. There is some medial based right knee pain, but
             overall reports improvement. Dr. -------- advised the patient to initiate a
             work hardening program followed by a functional capacity evaluation.
             Follow up in ten weeks for final MMI and impairment rating.

             Dr. -------- returns the patient to light duty but no standing until next
             evaluated on February 13, 2001. A patella stabilizing knee sleeve was
             ordered for the right knee due to internal derangement of the knee.

02/13/01     Dr. -------- saw the patient for follow-up of his left calcaneus injury and
             also his right knee. The left hind foot is now stable. There is some
             continued mild anterior ankle-based pain, but the patient reports his heel is
             again stable and tolerable. Mr. Williams feels the previous hindfoot
             fusion has significantly improved his overall symptomatology. Regarding
             the right knee, he continues feeling pain along the medial aspect of the
             knee. He reported some continuing catching and swelling.
             Impressions:
             1. Status post open reduction internal fixation calcaneus frcture, left.
             2. Status post subtalar arthrodesis, left.
             3. Right knee pain, medial.
             The right knee was injected with Aristospan and Xylocaine today. Dr. ----
             ---- plans to see how the injection improves his overall symptomatology.
             The left hindfoot is at maximum medical improvement. The functional
             capacity evaluation is set for March 1. Mr. Williams is to continue with
             the same restrictions.

05/09/01     Dr. -------- reports the patient has ongoing pain in the knee, principally in
             the medial compartment where he was noted to have Grade III
             chondromalacic changes in association with a torn medial meniscus. His
             recovery from the arthroscopic surgery has been limited at best, and he
             continues with ongoing medial compartment knee pain. Dr. --------
             suspected a worsening and deterioration of the chondromalacic lesion. Dr.
             -------- re-arthroscoping and re-debriding the knee, and he could consider
             an OAT’s procedure. This is to be scheduled.




                                                                                         10
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99



06/11/01     Operative Report
             Surgeon: ----------, M.D.
             Preop DX: Suspected recurrent chondromalaciac lesions involving the
             medial compartment of the right knee.
             Postop DX: Grade III and IV chondromalaciac changes in two areas of
             the medial femoral condyle with a recurrent tear in the remaining postion
             of the medial meniscus.
             Procedure:
             Operative arthroscopy with debridement of chondromalacia and micro-
             fracture of Grade IV lesions on the medial femoral condyle and
             redebridement of torn portion of medial meniscus.

06/18/01     The patient followed up with Dr. -------- and reported getting along
             reasonably well, with moderate swelling. The pain level is decreasing but
             may be higher than expected, but not higher than anticipated. Dr. --------
             allowed weight-of-leg only, and start range of motion and resistance
             exercising without weightbearing. Patient cannot sleep at night, do
             Dalmane was prescribed. Physical therapy will be started.

07/02/01     The patient is still fairly symptomatic and very anxious about his knee and
             its prognosis. Dr. -------- felt he was doing about as well as could be
             expected. He is having some medial compartment pain, patellofemoral
             pain and some swelling. He should continue with crutches and bare
             minimum weight and return in three to four weeks.

07/05/01     Prescription to continue physical therapy for three to four weeks, one or
             two times a week.

08/01/01     Mr. Williams continued with localized pain in the medial femoral condyle,
             although the anterior pain seems to have been relieved. He is not
             sufficiently improved to return to his usual, normal and customary work
             activities. He also continues to have problems with an ankle. Dr. --------
             offered a depo-steroid injection which the patient declined because he had
             not had a good response from injections in the past. The patient was
             advised to continue conservative treatment with a home exercise program
             and restriction on physical activity. He is to use a knee support and
             alternating ice and heat, with nonsteroidal anti-inflammatories for the next
             three to four weeks. Failing further recovery, Dr. -------- noted the only
             options he would consider would be further surgical intervention – either a
             hemiarthroplasty versus an osteochondral transplant or tibial osteotomy.




                                                                                         11
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99


08/22/01     The patient returned and elected to go ahead with injection therapy. The
             other alternative was discussed should he not respond to conservative
             management. This was done.

09/20/01     The patient is still having pain and difficulty in the right knee. The
             injection improved but did not eliminate his symptoms. He will be
             reviewed by Dr. -------- for possible corrective proximal tibial osteotomy.

11/14/01     -----------, M.D.
             Mr. Williams was seen by Dr. -------- today for follow-up of his right
             medial compartment arthritis. We had discussed doing an osteotomy and
             he got a medial compartment unloading brace which he felt gave him
             significant improvement for the knee. He feels less discomfort with the
             brace, but cannot wear it for longer periods of time. The patient has
             decreased his smoking from 2 ½ packs a day down to one pack a day.
             On examination there was effusion present in the right knee. He has pain
             to palpation along the medial joint line.
             Impression:
             1.       Right knee pain
             2.       Right knee varus deformity of the knee.
             3.       Right knee effusion.
             4.       Right knee medial compartment degenerative joint disease.
             Dr. -------- noted that with Mr. Williams’ severe degenerative changes in
             the medial compartment, he is at some point going to require joint
             replacement; however, at age 42, it would be to the patient’s benefit to
             hold off on this. As an option, one that would give him 10 to 12 years of
             improvement, would be a high tibial osteotomy done with distraction
             calistasis technique.

             The biggest concern that Dr. -------- had with Mr. Williams is tht he
             absolutely has to discontinue smoking and be in a non-smoking
             environment during the time that the distraction calistasis technique is
             being done, and this would take three to four months following the
             surgery. By early January they hoped to have him completely off
             smoking, and they would schedule the high tibial osteotomy at that time.

             On this date Dr. -------- wrote to Jon --------, M.D., asking that Dr. --------
             help the patient establish a cessation of smoking program. Dr. -------- said
             he absolutely had to have Mr. Williams completely off cigarettes and
             nicotine for about four months around the time of the osteotomy.

01/23/02     The patient returned to see Dr. --------, continuing with pain in the medial
             aspect of the right knee. He stopped smoking on January 10. His wife



                                                                                         12
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99


             discontinued smoking in November. It was recommended that he proceed
             with the high tibial osteotomy as scheduled on February 5.

02/05/02     Operative Report – -------- LGT Medical Center East
             Surgeon: -----------, M.D.
             Assistant: ----------, PA-C.
             Preop DX: Medial compartment arthrosis, right knee, with varus
             deformity of the leg.
             Postop DX:
             1.     Right knee medial compartment arthrosis with medial meniscus
                    tear.
             2.     Right leg varus alignment.
             Procedure:
             1.     Right leg high tibial osteotomy.
             2.     Right knee arthroscopy partial medical meniscectomy.
             3.     Right leg application of external fixator uniplaner.

02/13/02     Dr. -------- saw Mr. Williams in follow-up of his high tibial osteotomy.
             His pain has been controlled with OxyContin in combination with Ultram.
             The findings were discussed with the patient and the automated distractor
             was activated for a millimeter a day distraction.

02/20/02     Examination today shows a little bit of serosanguinous drainage with some
             fibrinous material at the proximal pin sites.
             X-rays: 51” long leg x-rays show the weightbearing axis to be in the
             medial joint space. There is distraction across the osteotomy site.
             Impression:
             1.      Status post left high tibial osteotomy.
             2.      Left leg pain.
             The patient was to continue with distraction calistasis at a rate of 1 mm a
             day. Refilled OxyContin, prescribed Percocet, Ultram and Ambien.

03/01/02     Refilled OxyContin, 10 mg, #50,and prescribed Clindamycin, 300 mg,
             #30.

03/12/02     No deep infection is seen. There is some mild drainage around the
             proximal pin sites.
             X-rays: The weight bearing line is now in the center of the knee joint,
             about 5 mm medial to where our ideal point for alignment would be.
             Impressions:
             1.     Status post high tibial osteotomy, right knee.
             2.     Right knee degenerative joint disease.




                                                                                       13
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99


             Dr. -------- asked the patient to continue with lengthening over the next
             four days. He was to turn the automated distractor off at noon on Saturday
             and be seen next week.
             Refilled Ambien, Percocet #50.

03/19/02     Mr. Williams reports increased discomfort since he stumbled the other day
             and almost fell. He felt a jarring sensation in his right leg. There is mid
             swelling in the right leg.
             X-rays: A 51” long leg film shows his weightbearing axis to be through
             the lateral tibial spine. He is at the 62% lateralization point, which was the
             predicted end point.
             Dr. -------- advised the patient to begin to decrease his pin tract treatments.
             He will wean down on his Percocet and OxyContin, which was discussed
             in detail. Return in four weeks. Refilled Percocet, #50, and OxyContin,
             #60.

04/16/02     The patient reports he has been able to progressively put more weight on
             his right leg, but he still has pain in the osteotomy site and in the knee
             area. No evidence of infection, minimal swelling of the knee.
             X-rays: AP and lateral views of the right tibia at the osteotomy sites are
             of good regenerate bone medial and lateral and posterior aspects. There is
             still significant regenerate bone needing to be formed medially and
             anteriorly.
             Dr. -------- advised the patient to wean down off of his pain medication
             and continue local pin tract care. Oxycontin was renewed, #20. Percocet
             was renewed, #50.

05/14/02     Mr. Williams is still having pain in the patellofemoral area of the knee and
             around the medial proximal pins. He is able to bear eight on the leg. He
             is weaning himself off the narcotic medication and is down to 10 mg. of
             OxyContin daily and uses breakthrough Percocet.
             X-rays: AP and lateral views are obtained of the right tibial osteotomy
             site. There appears to be good consolidation posteriorly, medially and
             laterally. Anteriorly there is still some lucency. There has been
             progressive healing of the regenerate bone.
             Impressions:
             1.      High tibial osteotomy, right knee.
             2.      Right knee pain.
             3.      Patellofemoral pin in the right knee.
             4.      Retained external fixator of the right knee.
             Dr. -------- recommended that he dynamize his external fixator, and this
             was done by release of the central locking nut.
             Prescribed OxyContin, #20, and Percocet, #50.



                                                                                         14
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99


05/24/02     They dynamized the fixator when he was last in, but he felt there was
             some compression occurring at the fixator, so they locked the central
             body, locking that. He continues to bear weight on it.
             X-rays: The osteotomy site continues to consolidate. Good bone
             formation is present posteriorly, medially and laterally. Anteriorly he is
             still deficient.
             Dr. -------- will be maintained in his fixator for another week. Dr. --------
             released the central body locking nut and asked him to bear weight.
             Percocet was prescribed, #30.

05/31/02     Mr. Williams has been able to wean off the OxyContin. He has been
             weightbearing on the left with no real changes in his pain pattern. He still
             walks with an antalgic gait.
             X-rays: A 51” long leg film shows the weightbearing axis is passing
             through the center of the knee joint. The oseotomy appears to have
             consolidated well with good regenerate bone.
             Dr. -------- felt Mr. Williams should undergo removal of the external
             fixator. This is scheduled. Percocet was prescribed, #50.

06/05/02     The Orthopedic Surgery Center of --------.
             Operative Report
             Surgeon: -----------, M.D.
             Pre & Postop DX: Retained external fixator of the right leg.
             Procedure: Removal of external fixator, right leg, under anesthesia.

             Mr. Williams was referred for physical therapy for range of motion and
             rehabiliation for the right leg.

06/25/02     Mr. Williams was seen for follow-up of his high tibial osteotomy on the
             right. He also would like to have the hardware removed from the subtalar
             fusion of his left foot because of pain.
             X-rays: The left subtalar fusion shows what appears to be a good fusion
             on the posterior aspect of the subtalar joint. There is a question of whether
             or not this is fused. The screw has a little bit of a windshield wiper effect
             on it.
             Impressions:
             1.      Subtalar fusion with painful hardware.
             2.      Status post high tibial osteotomy.
             3.      Degenerative joint disease, right knee.
             Dr. -------- recommended a Tomogram evaluation of his subtalar fusion to
             be sure the fusion is stable before removing the screw. He recommended
             injection to the right knee joint for his arthritis. This was done today. He
             was started on Vioxx, 25 mg.daily.



                                                                                         15
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99


07/18/02     The Orthopedic Surgery Center of --------
             Operative Report:
             Surgeon: -----------, M.D.
             Pre & PostopDX: Painful retained hardware of the left calcaneus
             following talocalcaneal fusion.
             Procedure:     Removal of painful retained hardware of the left calcaneus.

09/18/02     Mr. Williams was seen for follow-up of his right knee patellar fracture,
             still having difficulty with his gait pattern. He still has difficulty with his
             gait pattern and he has pain in the medial parapatellar area. He has not
             gotten back to the same level of walking that he had prior to his patellar
             fracture. There is a trace effusion in the joint.
             X-ray examination of the right knee shows the fracture is healed. There
             is minimal deformity to the patella.
             Impression:
             1.       Right knee patella fracture.
             2.       Patellofemoral pain, right knee.
             Dr. -------- felt the patient should continue physical therapy, trying to
             normalize his gait pattern. They can’t do much with the knee until his gait
             pattern returns to normal. Arthroscopy may be necessary if he has
             persistent swelling in the joint. Dr. -------- advised physical therapy to
             emphasize extension and gait pattern once or twice a week for one week.

10/16/02     Mr. Williams continues to have catching and popping sensations behind
             the kneecap and swelling by the end of the day. He feels he is walking
             better but physical therapy has not resolved all of his symptoms.
             Impressions:
             1.      Right knee pain.
             2.      Patella chondromalacia of the right knee.
             3.      Right knee effusion.
             The patient was to continue with activities as tolerated, but right knee
             arthroscopy will be scheduled for debridement of the joint. Dr. -------- did
             not feel the patient would get much further with physical therapy. The
             patella is healed, but the patient has sustained some cartilage damage to
             the patella and trochlea because of the impact at the time of the
             automobile accident.

             Dr. --------, wrote to Dr. --------, requesting a preop H&P for Mr. Williams.

11/01/02     ---------- Regional Medical Center
             Operative Report
             Surgeon: D. P. --------, M.D.




                                                                                         16
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99

             Preop DX: Chondromalacia of the patella, right knee.
             Postop DX: Right knee chondromalacia of the patella and trochlea.
             Procedure:
             Right knee arthroscopic examination and chondroplasty of the patella and
             trochlea.

11/07/02     Mr. Williams returns today for postop evaluation of his right knee. He is
             still having some postop discomfort and has noticed a catch on the medial
             side of his knee. This was present prior to the scope but is more intense.
             He tales Percocet once or twice a day. He is using his cane when outside
             the house. He was encouraged to take anti-inflammatory medication for
             the discomfort and inflammation in the knee and was to begin physical
             therapy tomorrow. The catch on the medial side of his knee could be due
             to either scar tissue or inflammation.

12/02/02     The patient states he is having pain along the medial joint line of the right
             knee with a catching sensation. At this point Dr. -------- had nothing
             further to offer him in terms of treatment. His use of medications is
             markedly improved in that he takes no pain medication even though he
             does have pain with walking. He does have an impairment related
             specifically to the patella fracture and also to the medial compartment, but
             these should be considered separately. Dr. -------- feels the patient has
             reached MMI relative to both problems in the knee.

12/26/02     In a letter to --------, Attorney at Law, Dr. -------- responds to questions in
             a letter from the attorney dated December 4, 2002. Mr. Williams was
             involved in a MVA on August 16, 2002, at which time Dr. -------- treated
             him for a nondisplaced patellar fracture. Chondromalacia was
             subsequently identified of his kneecap. These injuries were directly
             related to the automobile accident. The prognosis is essentially full
             functional recover currently. Chondromalacia of the knee does result in
             permanent impairment of the knee. The patient needs no further surgical
             treatment but may need medical treatment with cortisone injections or
             physical therapy in the future. There is also degenerative changes of the
             medial compartment of the knee, much more profound than his
             patellofemoral chondromalacia. If this requires surgical treatment in the
             future, Dr. -------- felt it would be a result of his pre-existing
             degenerative changes in the knee. There are no limitations relative to
             his work or activities related to the MVA. There is a permanent
             impairment as a result of the MVA of 5 percent of the right lower
             extremity because of the direct impact to the knee with patella
             fracture and resultant chondromalacia of the patella.




                                                                                          17
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99

08/01/03     Recently Mr. Williams has had more discomfort and swelling in the knee
             and he has popping sensations along the medial side. Dr. -------- felt he
             probably had a synovitis causing some of the joint line to rub on the
             medial femoral condyle, and recommended a cortisone injection. The
             right knee was injected into the suprapatellar pouch with 5 ccs of
             Lidocaine, 5 ccs of Marcaine and 2 ccs of Celestone.
             Impressions:
             1.      Right knee pain.
             2.      Right knee degenerative joint disease.
             3.      Right knee effusion.
             Mr. Williams was restricted to sedentary to light work.

09/10/03     Mr. Williams was still having pain in the medial aspect of the knee with a
             catching sensation that was really bothering him. He did not feel that the
             injection last month was of any benefit. Now Dr. -------- added a loose
             body in the right knee to the impressions noted above. He
             recommended an arthroscopy to assess for a possible loose body in the
             medial joint line. The patient was to remain off work.

11/03/03     In a letter to Mr. -----------, RN. of Med Secure, Inc., Dr. -------- noted Mr.
             Williams’ present diagnoses remains osteoarthritis of the medial
             compartment of the right knee. Now he has the new onset of pain in the
             medial aspect of the knee, the sensation of a loose body. There isn’t really
             any way to totally sort out the two liability situations. Dr. -------- felt
             the patellofemoral problems were related to the motor vehicle
             accident, as opposed to the medial compartment problems. He did
             not anticipate more treatment needed for the right knee injury as it
             relates to the work injury of June 17, 1999. In the long run, the
             patient will require total joint replacement.

12/04/03     -------- Orthopedic Center Surgery Center
             Operative Report
             Surgeon:       --------las --------, M.D.
             Preop DX: Internal derangement, right knee, with loose bodies.
             Postop DX: Right knee chondral loose bodies, multiple.
                          Right knee medium compartment degenerative arthrosis.
                          Right knee patellar chondromalacia.
             Procedure: Right knee arthroscopic removal of multiple loose bodies.

12/08/03     Patient is doing well following the surgery. No longer on pain
             medications. Mr. Williams was to continue with limited activites, icing,
             elevation and use of an anti-inflammatory. Seen this date by ------, PA-C.




                                                                                         18
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99
01/14/04    Mr. Williams has had improvement in the anteromedial pain that he had
            prior to arthroscopy, but still has pain in the front portion of the knee.
            There is 1 to 2+ patellofemoral crepitation with 1+ crepitus in the medial
            compartment. There is pain to palpation around the patellar tendon
            region. The patient was advised by Dr. -------- to progress activities as
            tolerated but to avoid prolonged periods of standing and he should not
            kneel or squat. He should be in a sedentary light category of work relative
            to the knee. There are permanent restrictions. Mr. Williams has
            reached MMI relative to his knee, and would see Dr. -------- on an as-
            needed basis.
            Impressions:
            1.      Right knee pain.
            2.      Right knee medial compartment degenerative joint disease.
            3.      Status post high tibial osteotomy.
            4.      Status post patellar fracture.
            5.      Chondromalacia of the patellofemoral articulation.
            6.      Effusion, right knee.
            7.      Quadriceps atrophy of the right knee.
            The patient could return to sedentary/light work with restrictions.

03/09/04      In a letter to ----------, RN, Med Secure, Inc., Dr. -------- noted he did not
              expect Mr. Williams would require any immediate diagnostic studies or
              interventions relative to his work injury, but did feel that in the course of
              the next 10 to 15 years he would probably require total knee
              arthroplasty. The patient was released to a sedentary light work
              category relative to the right knee, he should not squat, kneel or stand
              for a prolonged period, with a maximum time of three hours during an
              eight hour work day. Mr. Williams has a permanent impairment as it
              relates to his work injury, manifested as post traumatic degenerative
              arthritis of the knee. He did reach MMI on January 14, 2004 relative
              to his right knee.

03/09/04      In a letter to Attorney -----------, Dr. -------- reiterated that stated in the
              letter to Mr. ---------- this date. He noted previous physicians felt the
              patient did sustain injury to his right knee from a fall from a ladder.
              Dr. --------- did feel Mr. Williams probable knee replacement sometime
              in the next 15 years. Limitations would be no running, squatting or
              kneeling. He cannot stand more than three hours a day and this
              should be done on an intermittent basis.

              These restrictions would be permanent because of the degenerative joint
              disease. According to the AMA Guides, Fourth Edition, with no cartilage
              remaining in the medial femoral condyle and medial tibial plateau,




                                                                                           19
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99
            this impairment should be a 50 percent impairment of the right lower
            extremity.

There is a list of all x-rays taken at the Orthopedic Surgery Center of --------, with
diagnoses.

There are medication sheets for all prescriptions filled from 1999 through 11/17/03.

There is a flow chart of all visits to the -------- Orthopedic Center from 1999 through
12/03/02.

-------- Foot & Ankle – -------- P. --------, M.D.

12/09/02       Mr. Williams was seen for evaluation of his left lower extremity. He
               previously had undergone a left subtalar arthrodesis following a hindfoot
               fracture. He had previously undergone multiple surgeries to his right knee
               by Dr. D. --------. He continued with hindfoot pain on the left. He has
               undergone previous hardware removal by Dr. --------, as well. An
               examination was done, and x-rays were taken.
               Impression:
               1.      Nonunion, subtler joint arthrodesis, left foot.
               2.      Foot pain, left foot.
               A fine-cut CT scan will be obtained across the level of the nonunion. If
               this does reveal a nonunion, considerations include a repeat arthrodesis
               procedure across this level.

12/23/02       The patient continued with left foot pain and some anterior ankle pain on
               the left. The CT scan reveals nonunion across the level of the subtalar
               joint.
               Diagnoses:
               1.       Internal derangement, left ankle.
               2.       Nonunion, subtalar joint arthrodesis, left.
               Treatment options were discussed at length, and Mr. Williams elected to
               proceed with repeat arthodesis across the level of the subtalar joint, and
               also ankle arthroscopy.

04/16/03       The patient returned for follow-up of his revision arthrodesis and left
               ankle arthrotomy. Overall, he was doing quite well, although he wanted
               refills of his pain medication and Ambien. On examination the incisions
               were well healed and gross function was intact. There was erythema
               between the lateral incision and the open reduction, internal fixation
               incision for the calcaneus fracture.




                                                                                          20
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99
Impression:
            1.      Status post revision arthrodesis, subtalar joint, left.
            2.      Status post anterior ankle arthrotomy with debridement, left.
            OxyContin and Ambien were refilled and Augmentin was prescribed. The
            patient is to initiate Betadine paint to the lateral incision once a day,
            immobilize in a Cam walker boot and continue nonweightbearing.

05/14/03      The patient was seen for follow-up of his ankle subtalar arthrodesis on the
              left. He denies significant complaints. X-rays were obtained, and once
              these are reviewed he will proceed with 25 percent weightbearing for two
              weeks and progress by 2 percent weekly. Mr. Williams will continue with
              his Cam walker boot and report for follow-up in eight weeks.
              Impression: Subtalar arthrodesis, left.

07/09/03      The patient reported that overall his foot feels better than it has over the
              last four years. Examination shows well-maintained overall alignment
              with no evidence of motion across the subtalar joint. Ankle motion is
              somewhat decreased with 10 to 15 degrees of dorsiflexion and 25 degrees
              of plantarflexion. Mr. Williams is to follow up in three months.

10/09/03      Mr. Williams reports minimal pain in the heel, primarily in the morning
              when first moving about. He indicates significant improvement compared
              to his prior symptomtology. At this time the patient will continue to
              progress activities. The date of the FCE and maximal medical
              improvement will depend somewhat upon the patient’s right knee.

01/08/04      The patient reports he is doing well. He does have continued difficulties
              walking on uneven surfaces. He will continue with current activities.

02/05/04      In a letter to -----------, Attorney at Law, Dr. -------- notes the diagnoses
              are:
              1.       Status post subtalar fusion, left hindfoot.
              2.       Retained hardware, hindfoot, left.
              3.       Status post open reduction, internal fixation calcaneus
                       fracture, left.
              Medical records document the injury occurring while the patient was at
              work on 06/17/99. He has received ongoing care since that time, also
              confirmed by medical records.
              The prognosis for the left foot and ankle is good in regard to return to
              function. The patient does have a fused subtalar joint, which will limit
              some activities, i.e. sports, long distance walking and sitting for prolonged
              periods of time. He may need hardware removal in future. He may also




                                                                                        21
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99
            need further treatment for the ankle with possibilities of arthroscopy or,
            over the long term, ankle fusion.
            No specific limitations or restrictions have been placed. Restrictions will
            basically be determined by his pain level. He should not job and should
            work in a job that allowed standing and sitting work combined.
            The arthrodesis is permanent and permanently removes motion at the
            subtalar joint. The early arthritis present at the ankle joint is also
            irreversible and may also be progressive.
            At this point the patient has reached MMI. Based on the AMA Guides,
            there is a 5 percent whole person impairment, 13 percent lower
            extremity impairment and 22 percent foot impairment. The
            combined values chart is on pages 604, 5 and 6 of the 5th Edition.

------------- - Medical Center

01/26/00       Surgeon’s Operative Record
               Surgeon: -------- P. --------, M.D.
               Pre and Postop DX:
               1.     Subtalar arthrosis, left hindfoot.
               2.     Lateral calcaneal impingement, left lower extremity.
               3.     Synovitis/impingement, left ankle.
               4.     Retained hardware, left calcaneus.
               Procedure:
               1.     Subtalar arthrodesis, left foot.
               2.     Ankle arthroscopy with synovectomy, left ankle.
               3.     Removal of retained hardware, left calcaneus.
               4.     Calcaneal ostectomy, left.

08/16/02       Mr. Williams was seen in the Emergency Room this date following a
               motor vehicle accident. He had been the unrestrained driver in a car
               which did not have airbags. He was going through an intersection, his car
               was hit on the rear panel and spun around. During the spinning, he
               accidentally hit the accelerator rather than the brakes, went up a curb and
               struck a parked Pepsi truck. He had cuts over his left eye from breking his
               sunglasses. He had right knee pain and a little bit of pain in his left upper
               chest/shoulder area. An examination was done and x-rays of the knee
               revealed a stable patella fracture as read by the radiologist when
               compared to his old films because he does have post osteotomy
               changes.

               The left eye lacerations were cleansed and sutured. After speaking with
               Dr. -------- on the phone, the ER doctor aspirated the knee of 130 ccs of




                                                                                           22
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99
            blood. The knee was covered with sterile gauze, an ACE bandage and a
            knee immobilizer.
            Assessments:
            1.      Patella fracture on the right.
            2.      Joint effusion, right knee.
            3.      Eyelid laceration X2, 1.5 and 2.5 cm in length and jagged.
            4.      Cheek laceration, 2 cm. in length.
            The patient was discharged in stable condition in the care of his wife, the
            same day. He was give wound care instructions, and was to see Dr. -------
            - for suture removal in five days. He was to stay in the knee immobilizer
            until he saw Dr. -------- next week. He was given Percocet, 75/500, #20.

Jon J. --------, M.D.

06/06/01       The patient was seen at the Community Outpatient Procedure/Observation
               with pain and instability of the right knee. He has had previous
               arthroscopies and presently has signs of a torn medial meniscus. He has a
               history of left foot and ankle injury and a history of bilateral inguinal
               hernia repairs.
               Diagnosis: Unstable right knee.

11/20/01       Mr. Williams is going to have an osteotomy on his knee and it is important
               for him to stop smoking. He was prescribed Wellbutrin SR daily for six
               days, then b.i.d. He was also advised on Nicotrol.

01/31/02       Dr. -------- saw the patient at ---------, with a complaint of deformity of the
               right knee. He is to have an osteotomy.

---------Physical Therapy & Sports Center

11/22/99       Mr. Williams was referred for therapy by Dr. --------, status post fracture,
               calcaneus and subtalar ankle strain.

11/29/99       Treatment notes are reviewed for the following two weeks.

01/10/00       In a letter to Dr. --------, -----------, P.T. relates the patient is not sure they
               have made significant gains while he was been with Midwest Physical
               Therapy. Passive motion has increased, but he is not getting much more
               active movement. On December 28, Mr. Williams preferred to wait until
               he had seen Dr. -------- to see if he should continue therapy.

04/19/00       Dr. -------- ordered a compression stocking for Mr. Williams.

05/10/00       Dr. -------- ordered a single point cane.




                                                                                                 23
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99
            Mr. Williams had been seen in therapy from April 17 through June 5,
            2000. Treatment notes are reviewed.

06/05/00      Mr. Williams stated he was still having a lot of pain on top of his foot
              which did not feel like muscle or tendon, but more like bone on bone. He
              was still limited in motion and strength.

09/28/00      Dr. John -------- ordered pre-op/post-op protocol – right knee arthroscopy
              for right medial meniscus tear.

06/22/01      In a letter to Dr. --------, therapist ----------- notes the patient had surgery
              on June 11, 2001, when some drilling in the knee was performed
              secondary to loss of cartilage. He also had knee arthroscopy.
              Assessment:
              ---------- had decreased quadriceps muscle contraction independently.
              He requires assistance today and has a dependent gait, all secondary
              to surgery.
              Goals were set and ---------- was to be seen two or three times a week for
              four to six weeks.

              Treatment notes from June 10 to July 8, 2002 are noted.

06/15/02      In a letter to -------- --------, M.D., the diagnoses is noted as status post leg
              lengthening secondary to high tibial osteotomy on the right. Surgery had
              been performed on February 5, 2002.

              Objective findings noted the patient was ambulating with a single point
              cane in the left upper extremity due to right knee pain. He feels he needs
              the cane unless he is inside the house. Range of motion of the right knee
              was 10 to 122 degrees of flexion. Girth measurements indicated some joint
              line swelling.
              Assessment: The patient has decreased quadriceps muscle contraction of
              the right lower extremity, poor gait ambulating with a single point cane in
              the left upper extremity and decreased range of motion of the right knee.
              All symptoms and gait analysis are consistent with the left ankle fusion as
              well as the diagnosis of arthritis in the right patellofemoral joint.
              Mr. Williams was to be seen two or three times a week for progression of
              quadriceps muscle strengthening, gait training and range of motion of the
              right knee.

06/24/02      In a letter to Dr. --------, therapist Darci -------- reported that over the past
              three visits the patient had continual patellofemoral complaints with any
              closed chain exercises. --------’s quadriceps muscles does not want to fire




                                                                                             24
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99
            due to joint line irritation. Ms. -------- questions whether aquatic therapy
            might be beneficial.

06/25/02       Dr. -------- wrote a prescription to continue therapy three times a week.
               Also on this date Dr. -------- prescribed Vioxx.

07/25/02       PA-C ---------- (with Dr. --------), prescribed continued physical therapy
               until August 28, 2002.

               Treatment notes are reviewed from July 10 through August 7, 2002.

08/21/02       Dr. -------- prescribes full range of motion on September 4, 2002.

12/17/03       Therapy initiated postop evaluation following his right knee scope on
               December 4, 2003. He was also seen on January 5, 2004.

St. -------- Regional West Medical Center Physical Therapy

06/21/00       Initial evaluation: Mr. Williams, apparently called --------, was seen
               today. The history was reviewed of his injury of June 17, 1999, when he
               fractured his left calcaneous while putting in an outdoor speaker at a car
               dealership. He had surgery on June 27, 1999 for ORIF. The patient stated
               he was not working because there was no light duty. His job required
               climbing a ladder and walking. Some days he felt he could do this, and on
               other days he feels the lack of inversion and eversion causes balance
               problems. He is using a cane at this time. On examination there was 0
               degrees of dorsiflexion and 25 degrees of plantarflexion.
               Assessment: Given the amount of time since the accident and the
               severity of the injury, as well as other factors such as the compression
               fracture, rehabilitation will be a challenge for this patient. We are
               planning to do work hardening for four weeks. He was to be seen
               twice this week and then five times per week until he sees Dr. --------.

07/18/00       A progress note indicates they were working on work hardening, focusing
               on ankle strengthening and cardiovascular. He has made significant
               progress in his endurance and ability since the initial visit. Mr. Williams
               probably could not handle a full eight hour day without experiencing
               fatigue and soreness in the ankle. He has done well and increased his
               amount of activity and ability to tolerate longer periods of walking,
               climbing ladders, etc. The right knee appears to be a more significant
               hinderance than the ankle. The patient is bow-legged on the right and
               pressure on the medial side of the knee may have done meniscus damage,




                                                                                            25
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99
            or some other possible injury. The patient would benefit from continued
            work hardening, but needs the knee pain analyzed so he is not limited.

07/20/00      Mr. Williams called to say he had a meniscus tear on the medial aspect of
              his right knee, and is probably going to have surgery in one or two weeks.

09/20/00      Mr. Williams has had 18 treatments to date. He made excellent progress
              during his work hardening and work conditioning. He is discharged from
              physical therapy as of today.

01/09/01      The patient was seen for another initial evaluation. He presented with a
              diagnosis of status post subtalar arthrodesis of his left foot and internal
              derangement of his left knee. His most recent knee surgery was October
              2, 2000. He now works for Alltel and presents for a work hardening
              program with a follow-up Functional Capacity Evaluation. He states his
              previous job was a Wire Tech, which involved a lot of ladder climbing,
              and he had concerns about going back to this, but he wanted to see if it
              was possible. He wears a neoprene patellar stabilization brace on the right
              knee and has foot orthotics in place. There is a very significant varus
              deformity of his right knee with a mild varus deformity on the left.
              Assessment:
              “--------” has some pretty significant retro deformity of his right lower
              extremity and demonstrates some strength deficits. It was felt he would
              benefit from a strengthening and progressive work conditioning and work
              hardening program.
              Short and long term goals were set and the patient was to be seen two to
              three times per week.

02/08/01      In a progress note, the therapist reports that Mr. Williams has made some
              progress in tolerance to functional activities such as ladder climbing, step-
              ups, up/down stairs/ramp. He has gained minimally in knee range of
              motion but has improved hamstring flexion. It was not felt he had reached
              his maximum potential, but his right knee pain is limiting him the most.

03/15/01      The Functional Capacity Evaluation Summary noted upper and lower
              manual muscle testing was within normal limits. Grip strength testing,
              range of motion measurements, cervical range of motion, lumbar range of
              motion, trunk rotation, straight leg raises and balance were testing. Gait
              was marked by a limp to the right. Also tested were lifting, static strength
              testing, dynamic lifting, carrying, climbing, positional tolerances,
              reaching, sitting, standing walking and endurance. Observed behaviors
              were tested such as pacing, discomfort/fatigue reports, pain levels, regions
              of discomfort/fatigue.




                                                                                        26
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99
            This evaluation was considered to be valid.

              His strengths were listed, functional limitations noted and primary
              recommendations listed. A secondary recommendation states that the
              patient was most limited in activity due to right knee pain rather than
              difficulty with the left ankle, it may be beneficial to re-evaluate the right
              knee. His current work level is medium to modified heavy physical
              demand level.

04/26/01       In a Discharge Summary it is noted that his knee pain was increasing.
              They did not make a great deal of progress towards increasing his
              functional tolerance or decreasing his pain. He was discharged from their
              active files.

DIAGNOSTIC STUDIES

06/18/99      ---------- Regional Medical Center
              A left calcaneal CT scan was obtained.
              Impression: Relatively severely comminuted calcaneus fracture with
              impaction. Fractures are present in the posterior joint space with
              some comminution and mild depression and displacement along its
              anterior portion and some distraction of the fracture line posteriorly;
              however, the central portion is flattened but not significantly
              depressed or displaced. Nondisplaced fracture in the anterior
              articulation.

              Frontal and lateral views of the left lower leg were obtained. There is no
              bony alignment of the left knee and left ankle.
              Impression: Negative left lower leg series.

06/16/00      St. -------- Community Health Center
              An MRI of the left ankle was performed.
              Conclusions:
              1. Mid and inferior talar body and diffuse calcaneal marrow edema.
                  Question post traumatic/surgical changes.
              2. Negative for talar dome or navicular osteochondritis dissecans.
              3. Intact anterior and posterior ankle tendons.
              4. Subtalar fusion.

08/25/00      ---------- Community Health Center
              Right knee MRI




                                                                                              27
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99
Conclusions:
             1.     Small undersurface degenerative tear involving the apex of the
                    posterior horn of the medial meniscus.
             2.     High signal change involving the posterior medial tibial
                    plateau, likely early degenerative bony change.
             3.     Intact cruciate and collateral ligaments.
             4.     Grossly normal appearing patella.

07/02/02     --------- Community Health Center
             Left calcaneal tomography.
             Impression: Prior calcaneal tibial fusion which appears intact,
             primarily anteriorly.

08/16/02     ---------- Community Health Center
             X-rays - five views of the right knee were taken status post motor vehicle
             accident.
             Impressions:
             1.       Acute fracture of the lateral aspect of the tibia.
             2.       Status high tibial osteotomy.

12/09/02     -------- Foot and Ankle
             X-rays - Two hindfoot views were obtained. The area of the subtalar
             posterior facet did not appear completely fused.

12/13/02     ---------- Regional Medical Center
             A CT scan of the ankle/foot without contrast and a CT Reformations
             were done due to an injury in 1999 with surgical fusion in 2000 and
             persistent pain.
             Conclusion:
             1.       Moderate degenerative change and irregularity of the
                      talocalcaneal joint margins, without evidence of bony fusion.
             2.       Moderate deformity of the calcaneus with central depression
                      along the superior aspect secondary to previous fracture
                      without acute bony abnormality otherwise.
             3.       Edematous changes of the subcutaneous soft tissues about the
                      ankle with apparent slight thickening of the posterior tibial
                      tendon perhaps representing tendonosis.

04/03/03     Surgeon’s Operative Report
             Surgeon: -------- P. --------, M.D.
             Preop DX:
             1.     Nonunion subtalar joint, left.
             2.     Anterior ankle impingement/synovitis, left.




                                                                                     28
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99
            Procedure:
            1.      Revision arthrodesis subtalar joint, left.
            2.      Anterior ankle arthrotomy with partial synovectomy/debridement,
                    left.

05/14/03       -------- Medical Center East
               X-rays – three views of the left foot. Comparison is made with outside
               radiographs.
               Impression:
               Status post subtalar joint effusion with a fixation pin and sclerosis of
               the joint suggesting some bony union.

07/09/03       -------- Medical Center East
               X-rays - Views of the left calcaneus show a subtalar joint fusion with a
               single cancellous screw. There is apparent bony fusion, overall
               similar in appearance to 05/14/03/ Posttraumatic deformity of the
               calcaneus is also noted.
               Left foot x-rays are compared with films of 05/14/03. The bones are
               demineralized.
               Impression: Status post subtalar joint fusion without acute hardware
               complication evident.

PHYSICAL EXAMINATION:

General:       Alert and oriented to person, place and time. No acute distress. Well
               developed and well nourished.

Vital Signs:   Blood Pressure:       170/100
               Pulse:                80
               Respirations:         18
               Temperature:          Afebrile
               Height:               5’6 ½ “
               Weight:               168 lbs.

Neck:          Neck is supple without lymphadenopathy or thyromegaly.

Heart:         Regular rate and rhythm. No murmurs, clicks or rubs.

Chest/Lungs: Clear to auscultation bilaterally.

Abdomen:       Soft, nontender and nondistended. No organomegaly. No masses or
               tenderness to deep palpation.




                                                                                       29
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99
Spine:      Lumbar Spine:
            Examination                       Finding        Comment
            Posture:
               • Scoliosis                    Negative
               • Lordosis                     Negative
               • Kyphosis                     Negative
            Palpation:
               • Muscles                      Normal
               • Tenderness                   Negative
               • Spinous process              Normal
            Gait                              Normal
            Range of motion:
               • Flexion                      Normal
               • Extension                    Normal
               • Side to side                 Normal
            Muscle strength screening:
               • Heel-toe walk                Normal
            Neurologic:
               • Reflexes (ankle, knee)       Normal
               • Strength                     Normal
               • Sensation                    Normal
               • Straight leg raise test      Negative
               • Femoral stretch test         Negative
            Other:
               • Peripheral pulses            Normal
               • Hip range of motion          Normal

Spine:        Thoracic:

             Examination                   Finding       Comment
             Posture:
                • Scoliosis                Negative
                • Kyphosis                 Negative
             Palpation:
                • Muscles                  Normal
                • Tenderness               Negative
                • Spinous process          Normal
             Range of motion:
                • Flexion                  Normal
                • Extension                Normal
                • Side to side             Normal

Cervical Spine:



                                                                       30
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99

            Examination                        Finding    Comment
            Posture:
               • Scoliosis                     Negative
               • Lordosis                      Negative
               • Kyphosis                      Negative
            Palpation:
               • Muscles                       Normal
               • Tenderness                    Negative
               • Spinous process               Normal
            Range of motion:
               • Flexion                       Normal
               • Extension                     Normal
               • Side to side                  Normal
            Other:
               • Shoulder Motion               Normal
               • Cervical Compression          Normal
               • Spurling test                 Normal
            Neurologic:
               • Reflexes (biceps,             Normal
                   triceps, brachioradialis)   Normal
               • Motor                         Normal
               • Sensory                       Normal


                     UPPER EXTREMITY EXAMINATION

                                  SHOULDER
                             RIGHT                        LEFT
Shoulder:
   • Strength                Normal                       Normal
   • Effusion                Negative                     Negative
   • Stability               Normal                       Normal
   • Crepitus                Negative                     Negative
   • Other
Shoulder Range of motion:
   • Flexion                 Normal                       Normal
   • Extension               Normal                       Normal
   • Abduction               Normal                       Normal
   • Adduction               Normal                       Normal
   • Internal rotation       Normal                       Normal
   • External rotation       Normal                       Normal




                                                                     31
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99

                                        ELBOW
                             RIGHT                          LEFT
Elbow:
   • Strength                Normal                         Normal
   • Effusion                Negative                       Negative
   • Stability               Normal                         Normal
   • Crepitus                Negative                       Negative
   • Range of motion         Normal                         Normal
   • Other
Elbow range of motion:
   • Flexion                 Normal                         Normal
   • Extension               Normal                         Normal
   • Supination              Normal                         Normal
   • Pronation               Normal                         Normal



                                        WRIST
                             RIGHT                          LEFT
Wrist:
   • Strength                Normal                         Normal
   • Effusion                Negative                       Negative
   • Stability               Normal                         Normal
   • Crepitus                Negative                       Negative
   • Range of motion         Normal                         Normal
   • Other
Wrist range of motion:
   • Extension               Normal                         Normal
   • Flexion                 Normal                         Normal
   • Radial Deviation        Normal                         Normal
   • Ulnar Deviation         Normal                         Normal


Skin:        No visible scar is seen in the upper extremities. Skin is normal.

Sensation:   No loss of sensation in the upper extremities. No abnormal sensation.

Motor:        Patient had active range of motion against gravity with almost full
              resistance. Muscle tone in the upper extremities is normal.

Atrophy:     No appreciable atrophy is seen in muscles of the upper extremities.


                     LOWER EXTREMITY EXAMINATION


                                                                                     32
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99

                                        KNEE
                             RIGHT                           LEFT
Knee:
   • Strength                Normal                          Normal
   • Effusion                Negative                        Negative
   • Stability (ligament)    Normal                          Normal
   • Crepitus                +                               Negative
   • Patellofemoral joint    Tender +                        Normal
   • Atrophy                 Negative                        Negative
                             Negative                        Negative
   • McMurray sign
Knee range of motion:
          o Flexion          140° and slightly painful.      140 degree
          o Extension        0 degree                        0 degree

                                        ANKLE
                             RIGHT                           LEFT
Ankle:
   • Strength                Normal                          Normal
   • Effusion                Negative                        Negative
   • Stability               Normal                          Normal
   • Crepitus                Negative                        Negative
   • Tenderness              Normal                          +
   • Range of Motion
   •   Flexion               45°                             20°
   •   Extension             20°                             10°


Foot:         The left foot is fused, with good adjustment. Neurovascular status in the
              foot is normal.

Skin:         There are scars from foot and ankle surgery on the left and from the right
              knee surgery. Skin is normal.

Sensation:    No loss of sensation in the lower extremities. No abnormal sensation.

Motor:        Patient had active range of motion against gravity with almost full
              resistance. Muscle tone in the lower extremities is normal.

Atrophy:      No appreciable atrophy is seen in muscles of the lower extremities.

Neurologic:   Gait is coordinated and even. Superficial touch, pain and vibratory
              sensation are intact bilaterally.




                                                                                       33
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99


X-RAYS were taken in this office today of the knee, two views of each knee (for
comparison), which showed medial osteoarthritis of the right knee.

Two views of the left ankle show early arthritis. Two views of the left foot show the
subtalar fusion in good alignment.

DIAGNOSES:

Workers’ Compensation Injuries:

   1.      Comminuted calcaneal fracture, left hindfoot.
   2.      Left ankle synovitis.

Pre-Existing Diagnoses:

   1.      Degenerative process, right knee.
   2.      Torn medial meniscus, right.
   3.      Fracture, right patella.
   4.      Grade III chondromalacia, medial femoral condyle.
   5.      Right leg varus alignment.
   6.      Old compression fracture, thoracic spine.
   7.      Possible addiction to narcotics.

DISCUSSION:

I have had the opportunity to carefully review all of the medical records provided, review
x-rays and perform a thorough physical examination. I will answer your questions in the
order in which they were given.

With Respect to the Left Ankle Injury

   1.      On what date did Mr. Williams reach maximum medical improvement?

           Mr. Williams was considered permanent and stationary by Dr. -------- on
           February 5, 2004, and I agree with this.

   2.      What permanent partial disability did Mr. Williams sustain to his left
           foot as a result of that injury?

           This is a complicated procedure, and I would please refer you to the
           explanations below and to Conclusion VII.




                                                                                        34
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99

   3.     What, if any, work restrictions would you recommend with respect to the
          left ankle injury?

          For the left ankle, no specific limitation or restriction is placed, as
          recommended by Dr. -------- on February 5, 2004.

With Respect to the Right Knee Injury

   1.     To a reasonable degree of medical certainty, is the right knee problem
          causally related to the incident of June 17, 1999? (The first reference that
          I find in the medical records with respect to any right knee problems is
          contained in the records of -------- Orthopaedic Center on July 20, 2000.)

          Absolutely NOT. (Dr. --------, on December 26, 2002, noted pre-existing
          degenerative changes in the knee.)

   2.     On what date did Mr. Williams attain maximum medical improvement
          with respect to the right knee injury?

          This is not applicable. The right knee has a degenerative process which is
          slowly deteriorating the condition of the knee. He last saw his orthopedic
          surgeon on January 14, 2003, so one could speculate that the right knee
          reached MMI at that time.

   3.     What permanent partial impairment does Mr. Williams have with
          respect to the right knee injury?

          a. Again, this is not applicable to the Workers’ Compensation injury. If we
             were to speculate, it would be as follows.

          b.   He had a patellar fracture in a motor vehicle accident on August 16,
               2002, which consisted of a five (5) percent disability to the body as a
               whole.

          c. He had a meniscectomy, and has chondromalacia of the patella. Based on
             the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition,
             this, too, would amount of five (5) percent of the body as a whole;
             however, this condition was pre-existing.

          c. The total of a. and b. above would, thus, give a 10 percent impairment to
             the body as a whole due to the right knee (which was pre-existing) and due
             to the motor vehicle accident and arthritis.




                                                                                         35
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99

         d. Looking to the ultimate future, should he require total knee replacement,
            then this would add another five (5) percent of permanent impairment,
            thus with a total impairment of all these things of fifteen (15) percent

   4.    What, if any, work restrictions would you recommend with respect to the
         right knee injury?

         He had restrictions before the right knee injury due to other causes (the left
         ankle), and I do not see that his restrictions would change much. He is unable
         to do much standing or walking and it is difficult for him to lift, bend, walk
         and go up and down stairs.

EXPLANATIONS

   1.    Diagnosis:

         a. Comminuted calcaneal fracture, left hindfoot.
         b. Ankle synovitis, left.

         •    He fell a distance of 6’, landing on rock, sustaining this comminuted
              fracture.

   2.    Other diagnoses (not related to Workers’ Compensation):

         a.   Degenerative process, right knee.
         b.   Torn medial meniscus.
         c.   Fracture, right patella.
         d.   Grade III chondromalacia, medial femoral condyle.
         e.   Right leg varus alignment.
         f.   Old compression fracture, thoracic spine.
         g.   Addiction to narcotics.

         •    He obviously has a degenerative process in the right knee and was
              involved in a motor vehicle accident on August 16, 2002.
         •    He had a compression fracture in the lower thoracic region and had a
              functional lifting capacity of no more than 35 lbs with repetition, and no
              more than 65 lbs maximum.
         •    The right knee problem has no direct or indirect relationship to the
              Workers’ Compensation injury.
         •    He had no complaints with regard to the right knee until July of 2000.
         •    MMI for the right knee is difficult to achieve, since the degenerative
              process in the right knee continues to deteriorate.




                                                                                           36
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99
  3.     Prognosis:

         a. For the left ankle, the prognosis is fair to good, as confirmed by Dr. -------
            - on February 5, 2004.
         b. For the right knee, the prognosis is good, as confirmed by Dr. -------- on
            December 26, 2002.

   4.    Etiology:

         The fall from the ladder on June 17, 1999 – Workers’ Compensation injury.

         •   All investigations and surgeries for the right knee have no relationship
             directly or indirectly with the Workers’ Compensation injury.
         •   For the right knee, refer to No. 2 above.

   5.    Investigation:

         No more investigation is needed.

         •   Obviously no more investigation is needed for the left ankle.
         •   None of the investigations for the right knee have anything to do with the
             Workers’ Compensation injury of June 17, 1999.
         •   Investigation and treatment for the left ankle/foot was excessive.

   6.    Treatment:

         a. Treatment for the left ankle has been satisfied.
         b. The right knee may need occasional follow-up.

         •   He has not seen a doctor for the past approximately 15 months.
         •   It would be best for the patient for him to go back to work as soon as
             possible.
         •   He needs to continue with a structured home exercise program.
         •   He should use over-the-counter medications – not narcotics.
         •   The right knee may need follow-up with the physician (this is not Workers
             Comp related).

   7.    Maximum Medical Improvement:

         a. As regards the left ankle, he reached maximum medical improvement on
            February 5, 2004.
         b. The right knee reached maximum medical improvement by December 2,
            2002.




                                                                                        37
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99

         •   Dr. -------- confirmed MMI on February 4, 2004,for the left ankle.
         •   Dr. -------- confirmed MMI on December 2, 2004, for the right knee.

   8.    Work Status:

         It would be my belief that he can return to light to medium duty.

         •   For the left ankle, there is no specific limitation or restriction placed, as
             recommended by Dr. -------- on February 5, 2004.
         •   For the right knee, he can lift up to 30 lbs and perform limited walking
             and standing.
         •   The right knee has an arthritic process and it is very difficult for him to
             lift, bend, walk and go up and down stairs, but this has nothing to do with
             the Workers’ Compensation injury in question.

   9.    Permanent Disability:

         Based on the AMA Guides to the Evaluation of Permanent Impairment, Fifth
         Edition, the following calculations are made and are further outlined in
         Conclusion VII.

         For the left ankle and foot:

         Left Foot:   There is a 21 percent permanent impairment to the foot itself.
                      There is a 15 percent permanent impairment to the left leg.
                      This computes to a six (6) percent whole body impairment.

         Left Ankle: There is a 10 percent permanent impairment to the ankle.
                     There is a 7 percent permanent impairment to the left lower
                     extremity.
                     This computes to a three (3) percent permanent impairment to
                     the body as a whole.

         Combined:    The above figures combined as per page 604 of the AMA Guide
                      shows:
                      29 percent impairment to the foot and ankle.
                      21 percent impairment to the left lower extremity.
                      This computes to nine (9) percent whole body impairment.

         For the right knee: This is speculation, and not related to the Workers’
         Compensation injury of June, 1999.




                                                                                        38
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99

         a. Patellar fracture, nondisplaced, healed, resulting in chondromalacia,
            there is a 12 percent permanent impairment to the right knee which
            computes to five (5) percent of the lower extremity. This is due to the mtor
            vehicle accident of August 16, 2002.

             In comparison to this, Dr. -------- gave a 5 percent disability to the right
             lower extremity (which computes to two (2) percent of the whole body).

         b. The meniscectomy, partial medial or lateral, plus the chondromalacia and
            the proximal tibial osteotomy, with a good result, has a permanent

         c. impairment of 25 percent to the knee itself, which computes to a ten (10)
            percent permanent impairment of the lower extremity.

         d. Patella, plus the medial femoral condyle equals a 12 percent permanent
            impairment to the knee and which computes to five (5) percent impairment
            to the right lower extremity. This is due to a pre-existing arthritis.

         e. In the ultimate future (10 to 15 years), with total knee arthroplasty (and
            there is a 99 percent rate of good results with this), combined with b. and
            c. above, there would be a 37 percent permanent impairment to the knee
            itself which would compute to a fifteen (15) percent impairment to the
            right lower extremity.

             Dr. -------- noted, from all of the above, a 50 percent total impairment to
             the right lower extremity, which would compute to twenty (20) percent
             impairment of the body as a whole.

   10.   Liability Factor (fear):

         The patient has not worked for six years. For the liability factor, this is very
         complex.

   11.   Summary:

         This case is a complex one with a Workers’ Compensation injury, a motor
         vehicle accident, pre-existing arthritis, etc. It was managed aggressively, has
         a lot of complications (blisters, non-union, etc.), with the liability factor
         (eleven surgeries and not working for six years), as well as possible narcotic
         dependency. Every orthopedic surgeon has a different opinion for this case,
         and I believe all factors possibly play a role.




                                                                                            39
Name: John B. Williams
DOB: 12/31/58
DOI: 06/17/99

The above analysis is based upon the available information at this time, including the
history given by the examinee, the medical records and tests provided, and the physical
findings. It is assumed that the information provided to me is correct. If more information
becomes available at a later date, an additional report may be requested. Such
information may or may not change the opinions rendered in this evaluation.

The examiner’s opinions are based upon reasonable medical certainty and are impartial.
Medicine is both an art and a science and although a claimant may appear fit for return to
duty there is no guarantee the claimant will not be re-injured or suffer additional injury
once he or she returns. The opinions on work capacity are to facilitate job placement and
do not necessarily reflect an in-depth direct threat analysis. Comments on appropriateness
of care are professional opinions based upon the specifics of the case and should not be
generalized, nor necessarily be considered supportive or critical of, the involved
providers or disciplines.

Any medical recommendations offered are provided as guidance and not as medical
orders. The opinions expressed do not constitute a recommendation that specific claims
or administrative action be made or enforced.

Thank you for the referral of this claimant. If you have further questions or comments,
please do not hesitate to contact my office.

Sincerely,



Anil K. Agarwal, M.D., F.A.C.S.
Board Certified Orthopedic Surgeon and
Independent Medical Examiner

AKA:bb

Enclosures:
Conclusions I through VII
AMA Guide pages 546 and 547
CV
Invoice




                                                                                          40