Preview
FILED: NASSAU COUNTY CLERK 02/03/2023 03:13 PM INDEX NO. 617067/2019
NYSCEF DOC. NO. 93 RECEIVED NYSCEF: 02/03/2023
JONATHAN E. LERNER, M.D., P.C.
Diplomate of the American Board of Radiology
29 EAGLE LANE
EAST HILLS, NEW YORK 11576
TEL (917) 439-6208
FAX (866) 841-7386
June 23, 2021
Kelly, Rode & Kelly
330 Old Country Road, Suite 305
Mineola, NY 11501
Claimant: Luis Rivera
DOB:
Claim #: 158730
DOI: 01/31/19
To Whom It May Concern:
At your request, I have reviewed the MRI study of the lumbar spine performed on the above
named individual.
This study was performed at Soul Radiology. The date of the accident was 01/31/19.
MRI STUDY OF THE LUMBAR SPINE
The study was performed on 02/21/19.
Multi-planar, multi-sequence imaging of the lumbar spine was performed.
The examination demonstrates normal alignment of the lumbar vertebrae. The vertebral bodies
are normal in height and contour. There is no evidence of a marrow infiltrative process.
There is loss of signal and height within the L5-S1 intervertebral discs consistent with
dehydration.
The conus is located at L1. There is no evidence of cord tethering.
At L5-S1, there is a mild diffuse disc bulge and bilateral facet osteoarthritis. There is
effacement of the thecal sac and mild bilateral neural foraminal narrowing.
There is no evidence of epidural/paraspinal mass or fluid collection.
FILED: NASSAU COUNTY CLERK 02/03/2023 03:13 PM INDEX NO. 617067/2019
NYSCEF DOC. NO. 93 RECEIVED NYSCEF: 02/03/2023
Claimant: Luis Rivera
Claim #: 158730
D/O/I: 01/31/19
June 23, 2021
Page 2
IMPRESSION:
At L5-S1, mild diffuse disc bulge and bilateral facet osteoarthritis. There is effacement of the
thecal sac and mild bilateral neural foraminal narrowing.
SUMMARY:
This study is performed adequately and is technically satisfactory.
Magnetic resonance imaging of the lumbar spine demonstrates mild diffuse disc bulge At L5-S1
and bilateral facet osteoarthritis. There is effacement of the thecal sac and mild bilateral neural
foraminal narrowing.
The above findings are seen in the setting of diffuse desiccation of the L5-S1 intervertebral disc
space levels which is consistent with degenerative disc disease and suggestive of a chronic
degenerative process as opposed to an acute traumatic event.
Additionally, disc bulges in the lumbar spine will be seen in up to 63% of asymptomatic
individuals (Jensen, MC, et al. New England Journal of Medicine, 1994; 331: 369-373), thus
findings are frequently nonspecific.
Furthermore, the finding of bilateral facet osteoarthritis at the above levels contributes to the
degree of effacement of the thecal sac and bilateral neural foraminal narrowing, further
suggesting a chronic degenerative process as opposed to an acute traumatic event.
The following findings are so common in an asymptomatic patient that they must be interpreted
with caution and in the context of a clinical situation.
Among patients in their 40s who are asymptomatic, an MRI will find about:
68% have disc degeneration
54% have disc signal loss
45% have disc height loss
50% have a disc bulge
33% have a disc protrusion
22% have an annular fissure/tear
18% have facet degeneration
8% have spondylolisthesis
Reference: Brinjikji W. Luetmer, P.H., Comstock B., Bresnahan B.W., Chen L.E., Deyo R.A.,
Halabi S., Turner J.A., Avins A.L., James K., Wald J.T., Kallmes D.F., AJNR 2015 April;
36(4): 811-816.
FILED: NASSAU COUNTY CLERK 02/03/2023 03:13 PM INDEX NO. 617067/2019
NYSCEF DOC. NO. 93 RECEIVED NYSCEF: 02/03/2023
Claimant: Luis Rivera
Claim #: 158730
D/O/I: 01/31/19
June 23, 2021
Page 3
Evaluation of this MRI examination reveals no causal relationship between the claimant’s
alleged accident and the findings on this MRI examination.
Thank you very much for referring this case for my review and please call with any questions.
I, Jonathan Lerner, M.D., being duly licensed to practice in the State of New York, affirm under
the penalties of perjury, pursuant to CPLR 2106, do hereby affirm the contents of the foregoing.
Sincerely,
Jonathan Lerner, M.D.
JL:pk
FILED: NASSAU COUNTY CLERK 02/03/2023 03:13 PM INDEX NO. 617067/2019
NYSCEF DOC. NO. 93 RECEIVED NYSCEF: 02/03/2023
JONATHAN E. LERNER, M.D., P.C.
Diplomate of the American Board of Radiology
29 EAGLE LANE
EAST HILLS, NEW YORK 11576
TEL (917) 439-6208
FAX (866) 841-7386
June 23, 2021
Kelly, Rode & Kelly
330 Old Country Road, Suite 305
Mineola, NY 11501
Claimant: Luis Rivera
DOB:
Claim #: 158730
DOI: 01/31/19
To Whom It May Concern:
At your request, I have reviewed the MRI study of the cervical spine performed on the above
named individual.
This study was performed at Soul Radiology. The date of the accident was 01/31/19.
MRI STUDY OF THE CERVICAL SPINE
The study was performed on 02/21/19.
Multi-planar, multi-sequence imaging of the cervical spine was performed.
The examination demonstrates straightening of the normal cervical lordosis. The alignment is
otherwise unremarkable. The vertebral bodies are normal in height and contour. There is no
evidence of a marrow infiltrative process. The anterior and posterior longitudinal ligaments are
intact. The facet joints appear normal bilaterally at all levels.
There is loss of height and signal within the C2-C3 through C5-C6 intervertebral discs
consistent with dehydration.
There is normal appearance of the cranio-cervical junction. The course, caliber, and signal of
the cervical cord are normal.
At C5-C6, there is a central disc bulge with effacement of the ventral subarachnoid space and no
evidence of central canal spinal stenosis or neural foraminal narrowing.
There is no evidence of epidural/paraspinal mass or fluid collection.
FILED: NASSAU COUNTY CLERK 02/03/2023 03:13 PM INDEX NO. 617067/2019
NYSCEF DOC. NO. 93 RECEIVED NYSCEF: 02/03/2023
Claimant: Luis Rivera
Claim #: 158730
D/O/I: 01/31/19
June 23, 2021
Page 2
IMPRESSION:
At C5-C6, central disc bulge with effacement of the ventral subarachnoid space and no evidence
of central canal spinal stenosis or neural foraminal narrowing.
SUMMARY:
This study is performed adequately and is technically satisfactory.
The above findings are seen in the setting of diffuse desiccation of the C2-C3 through C5-C6
intervertebral disc space levels which is consistent with degenerative disc disease and suggestive
of a chronic degenerative process as opposed to an acute traumatic event.
Additionally, disc bulges in the cervical spine will be seen in up to 57% of asymptomatic
individuals (Tersilem, et al. Radiology, 1987; 164:83-88), thus the findings are frequently
nonspecific.
Disc bulges with thecal sac compromise or central protrusions and extrusions without significant
neural foraminal compromise are clinically insignificant. The presence of neural foraminal
compromise is more important in determining the clinical signs and symptoms while the
presence of a central disc bulge, protrusion, or extrusion correlates poorly with clinical signs and
symptoms. Whenever there are multiple level disc lesions with neural foraminal compromise,
claimants are likely to have objective neurological deficits.
The following findings are so common in an asymptomatic patient that they must be interpreted
with caution and in the context of a clinical situation.
Among patients in their 40s who are asymptomatic, an MRI will find about:
68% have disc degeneration
54% have disc signal loss
45% have disc height loss
50% have a disc bulge
33% have a disc protrusion
22% have an annular fissure/tear
18% have facet degeneration
8% have spondylolisthesis
Reference: Brinjikji W. Luetmer, P.H., Comstock B., Bresnahan B.W., Chen L.E., Deyo R.A.,
Halabi S., Turner J.A., Avins A.L., James K., Wald J.T., Kallmes D.F., AJNR 2015 April;
36(4): 811-816.
FILED: NASSAU COUNTY CLERK 02/03/2023 03:13 PM INDEX NO. 617067/2019
NYSCEF DOC. NO. 93 RECEIVED NYSCEF: 02/03/2023
Claimant: Luis Rivera
Claim #: 158730
D/O/I: 01/31/19
June 23, 2021
Page 3
There is straightening of the normal cervical lordosis.
The straightening of the cervical spine is a nonspecific finding. This may be related to muscle
spasm. However, this finding can be technical in origin related to how the patient is positioned
in the MRI unit by the technologist during the examination.
Evaluation of this MRI examination reveals no causal relationship between the claimant’s
alleged accident and the findings on this MRI examination.
Thank you very much for referring this case for my review and please call with any questions.
I, Jonathan Lerner, M.D., being duly licensed to practice in the State of New York, affirm under
the penalties of perjury, pursuant to CPLR 2106, do hereby affirm the contents of the foregoing.
Sincerely,
Jonathan Lerner, M.D.
JL:pk
FILED: NASSAU COUNTY CLERK 02/03/2023 03:13 PM INDEX NO. 617067/2019
NYSCEF DOC. NO. 93 RECEIVED NYSCEF: 02/03/2023
JONATHAN E. LERNER, M.D., P.C.
Diplomate of the American Board of Radiology
29 EAGLE LANE
EAST HILLS, NEW YORK 11576
TEL (917) 439-6208
FAX (866) 841-7386
June 23, 2021
Kelly, Rode & Kelly
330 Old Country Road, Suite 305
Mineola, NY 11501
Claimant: Luis Rivera
DOB:
Claim #: 158730
DOI: 01/31/19
To Whom It May Concern:
At your request, I have reviewed the MRI study of the left shoulder performed on the above
named individual.
This study was performed at Soul Radiology. The date of the accident was 01/31/19.
MRI STUDY OF THE LEFT SHOULDER
The study was performed on 02/25/19.
Multi-planar, multi-sequence imaging of the left shoulder was performed.
The rotator cuff musculature is symmetric in size. There is normal signal without atrophy or
denervation edema present. The teres minor tendon is intact. The infraspinatus tendon shows
uniform contour and low signal. There is thickening and signal heterogeneity within the
insertion of the supraspinatus tendon consistent with tendinosis.
The acromion has a curved (Type II) morphology. There is moderate acromioclavicular joint
osteoarthritis with capsular hypertrophy and reactive marrow edema. No significant fluid is
seen within the subacromial/subdeltoid bursa.
The long head of the biceps tendon is maintained in anatomic location with an intact biceps
labral complex. The subscapularis tendon shows low signal intensity fibers inserting on the
lesser tuberosity and proximal humerus.
FILED: NASSAU COUNTY CLERK 02/03/2023 03:13 PM INDEX NO. 617067/2019
NYSCEF DOC. NO. 93 RECEIVED NYSCEF: 02/03/2023
Claimant: Luis Rivera
Claim #: 158730
D/O/I: 01/31/19
June 23, 2021
Page 2
The anterior labroligamentous complex is unremarkable. The posterior labrum is intact.
The articular cartilage of the glenohumeral joint is well maintained. There is no glenohumeral
joint effusion. There is no loose body or debris present within the glenohumeral joint. There is
no evidence of occult fracture or osteonecrosis.
IMPRESSION:
1. No evidence of fracture, rotator cuff or labral tear.
2. Thickening and signal heterogeneity within the insertion of the supraspinatus tendon
consistent with tendinosis.
3. Moderate acromioclavicular joint osteoarthritis with capsular hypertrophy and reactive
marrow edema.
SUMMARY:
This study is performed adequately and is technically satisfactory.
Magnetic resonance imaging of the left shoulder demonstrates thickening and signal
heterogeneity within the insertion of the supraspinatus tendon consistent with tendinosis.
Tendinosis refers to internal tendon degeneration. This occurs because of an imbalance between
tendon breakdown and tendon repair. Thus, tendinosis can result either from an increase in
breakdown from overuse, or from a decrease in the healing response.
Additionally, this is seen in the setting of a narrowed acromiohumeral interval secondary to
osteoarthritis at the acromioclavicular joint space, which is reflective of rotator cuff
impingement syndrome.
Abnormalities from impingement that affect the supraspinatus tendon can be associated with
symptoms of pain and collectively are referred to as impingement syndrome. It can be
characterized by acute or chronic shoulder pain induced by movements or by elevation and
rotation of the shoulder. It can occur in young athletes involved in repetitive movements,
muscle overdevelopment, as well as degenerative changes of the acromioclavicular joint space.
Evaluation of this MRI examination reveals no causal relationship between the claimant’s
alleged accident and the findings on this MRI examination.
Thank you very much for referring this case for my review and please call with any questions.
FILED: NASSAU COUNTY CLERK 02/03/2023 03:13 PM INDEX NO. 617067/2019
NYSCEF DOC. NO. 93 RECEIVED NYSCEF: 02/03/2023
Claimant: Luis Rivera
Claim #: 158730
D/O/I: 01/31/19
June 23, 2021
Page 3
I, Jonathan Lerner, M.D., being duly licensed to practice in the State of New York, affirm under
the penalties of perjury, pursuant to CPLR 2106, do hereby affirm the contents of the foregoing.
Sincerely,
Jonathan Lerner, M.D.
JL:pk
Preview
FILED: NASSAU COUNTY CLERK 02/03/2023 03:13 PM INDEX NO. 617067/2019 NYSCEF DOC. NO. 93 RECEIVED NYSCEF: 02/03/2023 JONATHAN E. LERNER, M.D., P.C. Diplomate of the American Board of Radiology 29 EAGLE LANE EAST HILLS, NEW YORK 11576 TEL (917) 439-6208 FAX (866) 841-7386 June 23, 2021 Kelly, Rode & Kelly 330 Old Country Road, Suite 305 Mineola, NY 11501 Claimant: Luis Rivera DOB: Claim #: 158730 DOI: 01/31/19 To Whom It May Concern: At your request, I have reviewed the MRI study of the lumbar spine performed on the above named individual. This study was performed at Soul Radiology. The date of the accident was 01/31/19. MRI STUDY OF THE LUMBAR SPINE The study was performed on 02/21/19. Multi-planar, multi-sequence imaging of the lumbar spine was performed. The examination demonstrates normal alignment of the lumbar vertebrae. The vertebral bodies are normal in height and contour. There is no evidence of a marrow infiltrative process. There is loss of signal and height within the L5-S1 intervertebral discs consistent with dehydration. The conus is located at L1. There is no evidence of cord tethering. At L5-S1, there is a mild diffuse disc bulge and bilateral facet osteoarthritis. There is effacement of the thecal sac and mild bilateral neural foraminal narrowing. There is no evidence of epidural/paraspinal mass or fluid collection. FILED: NASSAU COUNTY CLERK 02/03/2023 03:13 PM INDEX NO. 617067/2019 NYSCEF DOC. NO. 93 RECEIVED NYSCEF: 02/03/2023 Claimant: Luis Rivera Claim #: 158730 D/O/I: 01/31/19 June 23, 2021 Page 2 IMPRESSION: At L5-S1, mild diffuse disc bulge and bilateral facet osteoarthritis. There is effacement of the thecal sac and mild bilateral neural foraminal narrowing. SUMMARY: This study is performed adequately and is technically satisfactory. Magnetic resonance imaging of the lumbar spine demonstrates mild diffuse disc bulge At L5-S1 and bilateral facet osteoarthritis. There is effacement of the thecal sac and mild bilateral neural foraminal narrowing. The above findings are seen in the setting of diffuse desiccation of the L5-S1 intervertebral disc space levels which is consistent with degenerative disc disease and suggestive of a chronic degenerative process as opposed to an acute traumatic event. Additionally, disc bulges in the lumbar spine will be seen in up to 63% of asymptomatic individuals (Jensen, MC, et al. New England Journal of Medicine, 1994; 331: 369-373), thus findings are frequently nonspecific. Furthermore, the finding of bilateral facet osteoarthritis at the above levels contributes to the degree of effacement of the thecal sac and bilateral neural foraminal narrowing, further suggesting a chronic degenerative process as opposed to an acute traumatic event. The following findings are so common in an asymptomatic patient that they must be interpreted with caution and in the context of a clinical situation. Among patients in their 40s who are asymptomatic, an MRI will find about: 68% have disc degeneration 54% have disc signal loss 45% have disc height loss 50% have a disc bulge 33% have a disc protrusion 22% have an annular fissure/tear 18% have facet degeneration 8% have spondylolisthesis Reference: Brinjikji W. Luetmer, P.H., Comstock B., Bresnahan B.W., Chen L.E., Deyo R.A., Halabi S., Turner J.A., Avins A.L., James K., Wald J.T., Kallmes D.F., AJNR 2015 April; 36(4): 811-816. FILED: NASSAU COUNTY CLERK 02/03/2023 03:13 PM INDEX NO. 617067/2019 NYSCEF DOC. NO. 93 RECEIVED NYSCEF: 02/03/2023 Claimant: Luis Rivera Claim #: 158730 D/O/I: 01/31/19 June 23, 2021 Page 3 Evaluation of this MRI examination reveals no causal relationship between the claimant’s alleged accident and the findings on this MRI examination. Thank you very much for referring this case for my review and please call with any questions. I, Jonathan Lerner, M.D., being duly licensed to practice in the State of New York, affirm under the penalties of perjury, pursuant to CPLR 2106, do hereby affirm the contents of the foregoing. Sincerely, Jonathan Lerner, M.D. JL:pk FILED: NASSAU COUNTY CLERK 02/03/2023 03:13 PM INDEX NO. 617067/2019 NYSCEF DOC. NO. 93 RECEIVED NYSCEF: 02/03/2023 JONATHAN E. LERNER, M.D., P.C. Diplomate of the American Board of Radiology 29 EAGLE LANE EAST HILLS, NEW YORK 11576 TEL (917) 439-6208 FAX (866) 841-7386 June 23, 2021 Kelly, Rode & Kelly 330 Old Country Road, Suite 305 Mineola, NY 11501 Claimant: Luis Rivera DOB: Claim #: 158730 DOI: 01/31/19 To Whom It May Concern: At your request, I have reviewed the MRI study of the cervical spine performed on the above named individual. This study was performed at Soul Radiology. The date of the accident was 01/31/19. MRI STUDY OF THE CERVICAL SPINE The study was performed on 02/21/19. Multi-planar, multi-sequence imaging of the cervical spine was performed. The examination demonstrates straightening of the normal cervical lordosis. The alignment is otherwise unremarkable. The vertebral bodies are normal in height and contour. There is no evidence of a marrow infiltrative process. The anterior and posterior longitudinal ligaments are intact. The facet joints appear normal bilaterally at all levels. There is loss of height and signal within the C2-C3 through C5-C6 intervertebral discs consistent with dehydration. There is normal appearance of the cranio-cervical junction. The course, caliber, and signal of the cervical cord are normal. At C5-C6, there is a central disc bulge with effacement of the ventral subarachnoid space and no evidence of central canal spinal stenosis or neural foraminal narrowing. There is no evidence of epidural/paraspinal mass or fluid collection. FILED: NASSAU COUNTY CLERK 02/03/2023 03:13 PM INDEX NO. 617067/2019 NYSCEF DOC. NO. 93 RECEIVED NYSCEF: 02/03/2023 Claimant: Luis Rivera Claim #: 158730 D/O/I: 01/31/19 June 23, 2021 Page 2 IMPRESSION: At C5-C6, central disc bulge with effacement of the ventral subarachnoid space and no evidence of central canal spinal stenosis or neural foraminal narrowing. SUMMARY: This study is performed adequately and is technically satisfactory. The above findings are seen in the setting of diffuse desiccation of the C2-C3 through C5-C6 intervertebral disc space levels which is consistent with degenerative disc disease and suggestive of a chronic degenerative process as opposed to an acute traumatic event. Additionally, disc bulges in the cervical spine will be seen in up to 57% of asymptomatic individuals (Tersilem, et al. Radiology, 1987; 164:83-88), thus the findings are frequently nonspecific. Disc bulges with thecal sac compromise or central protrusions and extrusions without significant neural foraminal compromise are clinically insignificant. The presence of neural foraminal compromise is more important in determining the clinical signs and symptoms while the presence of a central disc bulge, protrusion, or extrusion correlates poorly with clinical signs and symptoms. Whenever there are multiple level disc lesions with neural foraminal compromise, claimants are likely to have objective neurological deficits. The following findings are so common in an asymptomatic patient that they must be interpreted with caution and in the context of a clinical situation. Among patients in their 40s who are asymptomatic, an MRI will find about: 68% have disc degeneration 54% have disc signal loss 45% have disc height loss 50% have a disc bulge 33% have a disc protrusion 22% have an annular fissure/tear 18% have facet degeneration 8% have spondylolisthesis Reference: Brinjikji W. Luetmer, P.H., Comstock B., Bresnahan B.W., Chen L.E., Deyo R.A., Halabi S., Turner J.A., Avins A.L., James K., Wald J.T., Kallmes D.F., AJNR 2015 April; 36(4): 811-816. FILED: NASSAU COUNTY CLERK 02/03/2023 03:13 PM INDEX NO. 617067/2019 NYSCEF DOC. NO. 93 RECEIVED NYSCEF: 02/03/2023 Claimant: Luis Rivera Claim #: 158730 D/O/I: 01/31/19 June 23, 2021 Page 3 There is straightening of the normal cervical lordosis. The straightening of the cervical spine is a nonspecific finding. This may be related to muscle spasm. However, this finding can be technical in origin related to how the patient is positioned in the MRI unit by the technologist during the examination. Evaluation of this MRI examination reveals no causal relationship between the claimant’s alleged accident and the findings on this MRI examination. Thank you very much for referring this case for my review and please call with any questions. I, Jonathan Lerner, M.D., being duly licensed to practice in the State of New York, affirm under the penalties of perjury, pursuant to CPLR 2106, do hereby affirm the contents of the foregoing. Sincerely, Jonathan Lerner, M.D. JL:pk FILED: NASSAU COUNTY CLERK 02/03/2023 03:13 PM INDEX NO. 617067/2019 NYSCEF DOC. NO. 93 RECEIVED NYSCEF: 02/03/2023 JONATHAN E. LERNER, M.D., P.C. Diplomate of the American Board of Radiology 29 EAGLE LANE EAST HILLS, NEW YORK 11576 TEL (917) 439-6208 FAX (866) 841-7386 June 23, 2021 Kelly, Rode & Kelly 330 Old Country Road, Suite 305 Mineola, NY 11501 Claimant: Luis Rivera DOB: Claim #: 158730 DOI: 01/31/19 To Whom It May Concern: At your request, I have reviewed the MRI study of the left shoulder performed on the above named individual. This study was performed at Soul Radiology. The date of the accident was 01/31/19. MRI STUDY OF THE LEFT SHOULDER The study was performed on 02/25/19. Multi-planar, multi-sequence imaging of the left shoulder was performed. The rotator cuff musculature is symmetric in size. There is normal signal without atrophy or denervation edema present. The teres minor tendon is intact. The infraspinatus tendon shows uniform contour and low signal. There is thickening and signal heterogeneity within the insertion of the supraspinatus tendon consistent with tendinosis. The acromion has a curved (Type II) morphology. There is moderate acromioclavicular joint osteoarthritis with capsular hypertrophy and reactive marrow edema. No significant fluid is seen within the subacromial/subdeltoid bursa. The long head of the biceps tendon is maintained in anatomic location with an intact biceps labral complex. The subscapularis tendon shows low signal intensity fibers inserting on the lesser tuberosity and proximal humerus. FILED: NASSAU COUNTY CLERK 02/03/2023 03:13 PM INDEX NO. 617067/2019 NYSCEF DOC. NO. 93 RECEIVED NYSCEF: 02/03/2023 Claimant: Luis Rivera Claim #: 158730 D/O/I: 01/31/19 June 23, 2021 Page 2 The anterior labroligamentous complex is unremarkable. The posterior labrum is intact. The articular cartilage of the glenohumeral joint is well maintained. There is no glenohumeral joint effusion. There is no loose body or debris present within the glenohumeral joint. There is no evidence of occult fracture or osteonecrosis. IMPRESSION: 1. No evidence of fracture, rotator cuff or labral tear. 2. Thickening and signal heterogeneity within the insertion of the supraspinatus tendon consistent with tendinosis. 3. Moderate acromioclavicular joint osteoarthritis with capsular hypertrophy and reactive marrow edema. SUMMARY: This study is performed adequately and is technically satisfactory. Magnetic resonance imaging of the left shoulder demonstrates thickening and signal heterogeneity within the insertion of the supraspinatus tendon consistent with tendinosis. Tendinosis refers to internal tendon degeneration. This occurs because of an imbalance between tendon breakdown and tendon repair. Thus, tendinosis can result either from an increase in breakdown from overuse, or from a decrease in the healing response. Additionally, this is seen in the setting of a narrowed acromiohumeral interval secondary to osteoarthritis at the acromioclavicular joint space, which is reflective of rotator cuff impingement syndrome. Abnormalities from impingement that affect the supraspinatus tendon can be associated with symptoms of pain and collectively are referred to as impingement syndrome. It can be characterized by acute or chronic shoulder pain induced by movements or by elevation and rotation of the shoulder. It can occur in young athletes involved in repetitive movements, muscle overdevelopment, as well as degenerative changes of the acromioclavicular joint space. Evaluation of this MRI examination reveals no causal relationship between the claimant’s alleged accident and the findings on this MRI examination. Thank you very much for referring this case for my review and please call with any questions. FILED: NASSAU COUNTY CLERK 02/03/2023 03:13 PM INDEX NO. 617067/2019 NYSCEF DOC. NO. 93 RECEIVED NYSCEF: 02/03/2023 Claimant: Luis Rivera Claim #: 158730 D/O/I: 01/31/19 June 23, 2021 Page 3 I, Jonathan Lerner, M.D., being duly licensed to practice in the State of New York, affirm under the penalties of perjury, pursuant to CPLR 2106, do hereby affirm the contents of the foregoing. Sincerely, Jonathan Lerner, M.D. JL:pk