LISA M. SHONES, Employee/Appellant, v. ST. MARY'S HOSP., SELF-INSURED/MAY FOUNDATION, Employer.
WORKERS= COMPENSATION COURT OF APPEALS
JUNE 2, 2000
CAUSATION - SUBSTANTIAL EVIDENCE. Substantial evidence supports the compensation judge=s finding that the employee had not sustained reflex sympathetic dystrophy of the right upper extremity.
Determined by: Rykken, J., Wheeler, C.J., and Wilson, J.
Compensation Judge: William R. Johnson
MIRIAM P. RYKKEN, Judge
The employee appeals the compensation judge=s denial of primary liability and permanent partial disability benefits for a right upper extremity injury. We affirm.
On July 22, 1993, Lisa Shones (employee) sustained an admitted left wrist injury while working in the dietary department of St. Mary=s Hospital (self-insured employer owned by the Mayo Foundation). Born on November 19, 1969, the employee was 23 years old when injured, and earned an average weekly wage of $383.28. On July 22, 1993, the employee was carrying two cases of baby formula weighing 50 pounds when she tripped and the cases fell on her left wrist. On October 19, 1993, the employee underwent surgery to reconstruct her left wrist ligaments. Sometime after this surgery, the employee was diagnosed with reflex sympathetic dystrophy (RSD) of the left upper extremity. This left wrist injury is not at issue.
After the employee developed left RSD, she claims that she avoided using her left hand to avoid pain, swelling, discoloration, and lack of mobility, and therefore used her right hand for all activities at work and at home. The employee claims that this overuse of her right hand led to a consequential Gillette right upper extremity injury diagnosed as RSD of the right upper extremity. The employee worked at various jobs with the employer after her injury, including facility operations, patient representative, and office clerk. These positions required computer data entry, filing, sorting papers and tearing paper from a printer, all of which the employee performed with her right hand. By 1995, the employee reported symptoms in both hands, including mottling of purple and red color, shiny skin coloring, sweating, pain, numbness, tingling, swelling, and stiffness in the joints. In August 1995, the employee was taken off work and given a restriction of non-repetitive jobs for her right hand.
In September 1995, the employee began working at the Mayo Store as a clerk. This job was easier for the employee since she could vary her tasks when she began to notice any symptoms. The employee continued to develop symptoms which would flare up with certain activities. The employee was taken off work in May 1998 after a flare up, and on July 30, 1998, was limited to working four hours per day. The employee worked at the Mayo Store position for four years in a temporary position, and applied for but did not receive a permanent position in the store. The employee continued to work for the employer in other positions, and the employee also attempted to start a side business selling clothing out of her home.
The employee underwent two QSART tests (quantitative sudomotor axon reflex test) for RSD. The first was performed on December 12, 1994, which revealed abnormal findings in the left upper extremity, but not the right. Another QSART was performed on July 5, 1996 which indicated improvement in her condition, possibly attributable to earlier treatment.
In May 1996, the parties entered into a Stipulation for Settlement, settling a claim brought by the employee for payment of permanent partial disability benefits relative to the employee=s admitted left wrist injury.
On January 20, 1998, the employee filed a claim petition for 28.5 percent permanent partial disability of the body as a whole, pursuant to Minn. R. 5223.0400 Subp. 1D, for reflex sympathetic dystrophy and overuse syndrome of the right upper extremity, payable as economic recovery compensation. The employee relied on the medical opinion of Dr. Ann Schutt, the employee=s treating physician at Mayo Clinic from March 1994 through April 1, 1997. Dr. Schutt is board certified in the area of physical medicine and rehabilitation; her practice included RSD as an area of interest, and she has presented lectures on the topic at medical conventions. Dr. Schutt opined in an October 29, 1997, report that the employee developed symptoms in her right upper extremity of mild reflex sympathetic dystrophy caused by her repetitive work and overuse of her right upper extremity to protect her left upper extremity. Dr. Schutt also opined that the employee had sustained a permanent partial disability to her upper right extremity as a result of her work activities and her overuse of the right hand while she was recovering from her surgery to the left wrist. Due to Dr. Schutt=s retirement, she had not seen the employee since April 1, 1997.
At the request of the employer, on April 15, 1998, the employee underwent a medical evaluation with Dr. William H. Lohman. Dr. Lohman is board certified in the area of internal medicine and preventive medicine - occupational medicine. He works in the area of occupational and environmental medicine, specializing in musculoskeletal disorders. Dr. Lohman concluded that the employee did not have reflex sympathetic dystrophy of the right hand, stating:
I have a number of problems with the diagnosis of reflex sympathetic dystrophy in the right hand. First of all, while reflex sympathetic dystrophy itself is rare, even more rare (if it occurs at all) is the onset of objective reflex sympathetic dystrophy as a result of cumulative trauma. This has been reported in several cases in the medical literature but remains an extremely controversial hypothesis. Secondly, it is equally unlikely for reflex sympathetic dystrophy to be episodic as claimed by Ms. Shones. In my own experience and in the medical literature, RSD is a chronic and progressive problem. It is not episodic. It does not have periods when all symptoms resolve spontaneously only to occur again without precipitation. Thirdly, I find it improbable that Ms. Shones could have the pattern of symptoms that she presents in the history today and yet never have had any objective clinical findings documented on any of the many clinic visits with the many physicians that she has consulted for her problems. The only finding that occurs with any regularity, and even then not with any consistency [is] swelling. As I found here today, Ms. Shones does have some swelling in her hands but it did resolve in my office once she was taken out of the splints, which she reports wearing constantly. In my opinion her swelling is most likely due to her splints and to holding hands still or in a dependent position. Fourth, Ms. Shones did not have a typical response to stellate ganglion blocks. The blocks did in fact paralyze the autonomic nervous system as evidenced by the development of transient Horner=s syndrome. But even though the autonomic nervous system was effectively blocked, Ms. Shones did not have a typical response and did not have any persisting benefit of stellate ganglion injections. This reprises the results of the previous series of blocks that she received for treatment of her left hand. Finally, Ms. Shones does not have any objective laboratory testing to support a diagnosis of RSD in the right hand. X-rays do not show any osteoporosis and autonomic nerve testing is normal except for minimal thermal asymmetries which the neurologist indicates can be attributed to the previous stellate ganglion blocks.
Dr. Lohman also concluded that the employee had not sustained any type of overuse syndrome in her right upper extremity:
In summary, it is my opinion that Ms. Shones does not have reflex sympathetic dystrophy of the right hand now and has not had reflex sympathetic dystrophy of the right hand. She has chronic pain of unproven etiology, which she attributes to her work activities. She specifically feels that she overused the right hand because of restrictions on the left. However, looking at her job duties in the modified jobs that she has held since her left hand injury, none of them have been characterized by long duration highly repetitive stereotypical activities which would lead to any kind of cumulative trauma disorder, never mind any reflex sympathetic dystrophy. Her modified duty jobs have been characterized by a variety of activities performed at her own pace. Even though she was working one-handed, this is not the type of mechanical stress that would cause sufficient trauma to the right hand to eventually result in reflex sympathetic dystrophy.
A hearing was held on July 14, 1999. The compensation judge accepted Dr. Lohman=s opinion and rejected Dr. Schutt=s opinion, and found that the employee had not proven that she had sustained RSD of the right upper extremity. The compensation judge denied the employee=s claim for permanent partial disability benefits, finding that the employee=s condition does not satisfy the criteria set forth in Minn. R. 5223.0410, subp. 7. The employee appeals.
STANDARD OF REVIEW
On appeal, the Workers= Compensation Court of Appeals must determine whether Athe findings of fact and order [are] clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted.@ Minn. Stat. ' 176.421, subd. 1 (1998). Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings must be affirmed. Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 60, 37 W.C.D. 235, 240 (Minn. 1984). Similarly, findings of fact may not be disturbed, even though the reviewing court might disagree with them, Aunless they are clearly erroneous in the sense that they are manifestly contrary to the weight of the evidence or not reasonably supported by the evidence as a whole.@ Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975).
To establish the compensability of a claimed consequential injury, the employee must establish both medical and legal causation for the claimed consequential disability. See Jackson v. Red Owl Stores, Inc., 375 N.W.2d 13, 17-18, 38 W.C.D. 170, 177 (Minn. 1985). "Medical causation is a distinct legal concept that concerns the connection between the primary injury and a later condition - - 'how far the range of compensable consequences is carried, once the primary injury is causally connected with the employment.'" Id. at 18, 38 W.C.D. at 178 (citing Wallace v. Judd Brown Constr. Co., 269 Minn. 455, 459, 131 N.W.2d 540, 543, 23 W.C.D. 362, 366 (1964)). As a general rule, where an injury or condition is found to have arisen out of and in the course of employment, an employer and insurer are liable for every natural consequence that flows from the injury or condition unless it can be shown that later disability is the result of an independent intervening cause. Nelson v. American Lutheran Church, 420 N.W.2d 588, 590, 40 W.C.D. 849, 851 (Minn. 1988); Rohr v. Knutson Constr. Co., 305 Minn. 26, 29, 232 N.W.2d 233, 235, 28 W.C.D. 23, 26 (1975).
Reflex sympathetic dystrophy is defined in the Minnesota Rules under Minn. R. 5223.0400, subp. 6 for motor loss, and Minn. R. 5223.0410, subp. 7 for sensory loss. The condition is deemed to occur if at least five of the following conditions persist concurrently: edema, local skin color change of red or purple, osteoporosis in underlying bony structures demonstrated by radiograph, local dyshidrosis, local abnormality of skin temperature regulation, reduced passive range of motion in contiguous or contained joints, local alteration of skin texture of smooth or shiny, or typical findings of reflex sympathetic dystrophy on bone scan.
Dr. Schutt diagnosed the employee as having RSD in her right upper extremity, finding that she exhibited the following factors: edema, local skin color change of red and purple, local dyshidrosis, abnormal skin temperature regulation, slight reduced passive range of motion and contiguous joints, and local alteration of skin texture. The compensation judge specifically accepted Dr. Lohman=s opinion that the employee had not sustained a diagnosis of RSD in her right upper extremity, over that of Dr. Schutt. The employee argues that the compensation judge erred by focusing on the employee=s diagnosis and not on her lack of function. However, Dr. Lohman emphasized that RSD is not an episodic condition that can come and go as the employee claimed, but is progressive or at least chronic. The employee=s medical records indicated that the employee did not demonstrate symptoms of RSD on examination on many occasions. The employee has not undergone a bone scan to determine whether a diagnosis of osteoporosis can be identified. Since the employee=s symptoms did not consistently show up on examination, Dr. Lohman concluded that the employee did not have RSD, and the compensation judge accepted Dr. Lohman=s opinion concerning diagnosis and causation.
It is the compensation judge's responsibility, as trier of fact, to resolve conflicts in expert testimony. Nord v. City of Cook, 360 N.W.2d 337, 342, 37 W.C.D. 364, 372 (Minn. 1985). Substantial evidence supports the compensation judge=s finding that the employee did not sustain reflex sympathetic dystrophy of her right upper extremity as a consequential result of her July 22, 1993, injury, and accordingly we affirm the compensation judge=s denial of permanent partial disability benefits.
 Gillette v. Harold, Inc., 101 N.W.2d 200, 21 W.C.D. 105 (Minn. 1960).