JOHN J. KARAKASH, Employee/Appellant, v. SUPERIOR ROCK BIT CO. and STATE FUND MUT. INS. CO., Employer-Insurer, and DEP=T OF LABOR & INDUS./VRU, BLUE CROSS/BLUE SHIELD, NORTHWEST ANESTHESIA, P.A., UNIVERSITY MEDICAL CTR./MESABI, and LUOMA CHIROPRACTIC CLINIC, Intervenors.
WORKERS= COMPENSATION COURT OF APPEALS
MAY 3, 2001
CAUSATION - SUBSTANTIAL EVIDENCE. Substantial evidence, including adequately founded expert medical testimony, supports the compensation judge=s finding that the employee=s low back condition was neither caused nor substantially aggravated or accelerated by his work-related activities.
Determined by: Rykken, J., Johnson, J., and Wheeler, C.J.
Compensation Judge: Donald C. Erickson
MIRIAM P. RYKKEN, Judge
The employee appeals from the compensation judge=s finding that the employee failed to prove that his low back condition was caused or substantially aggravated or accelerated by his work activities with Superior Rock Bit Company. We affirm the finding that the employee did not sustain an injury arising out of his employment.
John J. Karakash, the employee, worked as a machine operator for Superior Rock Bit Company, the employer, between February 1985 and April 8, 1996. The employee claims that on April 8, 1996, he sustained a Gillette-type injury to his low back that arose out of and in the course of his employment with the employer. Born on September 16, 1961, the employee was 38 years old as of April 8, 1996, and earned a weekly wage of $626.39. On that date, the employer was insured for workers= compensation liability by State Fund Mutual Insurance Company, the insurer.
As a machine operator, the employee performed various machining tasks, including machining holes into a portion of a steel forging called a Aleg,@ which included lifting the forgings, setting them on the machinery, clamping them into a fixture, and drilling them with a drill press. These forging pieces ranged in weight between 40 to 75 pounds. The employee testified that on average, he lifted a forging piece onto and off the machines approximately 75 times per work shift. The employee also testified that he worked overtime hours for the employer at various times during late 1995 and early 1996, at an average of two hours overtime work per day, and so worked with more than 75 forgings on many days.
The employee=s medical history includes a snowmobile accident in 1986 in which he bruised his ribs, medical treatment he received in January 1993 following a low back injury he sustained while shoveling snow and extensive treatment starting in 1995 for dizziness, headaches, neck and low back symptoms. Following his 1993 injury, the employee was taken by ambulance to Central Mesabi Medical Center Emergency Room where he reported an acute onset of back pain while shoveling snow. Objective findings included mild spasm at the L3 and L4 levels and positive straight leg raising test, but findings on x-ray were negative. Dr. Martin Hinz diagnosed the employee with lumbar disc syndrome and prescribed bed rest and pain medications. There are no medical reports in the record documenting follow-up medical treatment after his emergency room visit.
In June 1995, the employee consulted the Mayo Clinic as a result of dizziness, neck pain and low back pain. The employee reported that approximately one year earlier, he had experienced an acute onset of Aexcruciating pain in his left neck@ and that since that onset, he had been Ain a fog@ with a decreased level of energy. Dr. Jonathan Evans concluded that the cause of the employee=s current symptoms was not entirely certain. He stated that
I suspect that the cause of his symptoms may be multifactorial, with a component of deconditioning. His work is very physically demanding, and I suspect that he is simply exhausted by it. . . . Another possibility for his symptoms could be depression, although he did not have any vegetative symptoms of depression nor of anxiety.
(Ee. Ex. K.)
The employee was again examined at the Mayo Clinic on March 18, 1996, and again reported Aa sense of cognitive fogginess that is not true vertigo nor presyncope and is not associated with falling, loss of consciousness or alteration in walking. It is worse towards the end of the workday and better on weekends.@ He underwent numerous tests, including a CT scan and MRI of his head and neck. Dr. Bruce Krueger at the Mayo Clinic had no explanation for the employee=s sense of cognitive fogginess; cervical spine films and MRI of the cervical spine showed mild degenerative disc disease which Dr. Krueger found to be irrelevant to the employee=s symptoms. An EMG was normal; Dr. Krueger assured the employee about his overall neurological status, and recommended consultations with an ear, nose and throat (ENT) and occupational medicine specialist, due to the employee=s concern about noise exposure at work and about the effects of toxins and vibration. However, the employee advised Dr. Krueger that he was unable to stay in Rochester to undergo that further follow-up. The employee testified at hearing that the Mayo Clinic determined that he was exhausted from the job he was performing at that time. (T. 37.)
On Sunday, March 10, 1996, while at home, the employee walked through waist-deep snow with a snow rake to pull snow off a roof. He testified that he AI was pulling snow off of a roof. And I felt my back tighten up.@ (T. 38.) The employee consulted Dr. Arne Luoma, D.C. for chiropractic treatment. Dr. Luoma=s chart note on March 11, 1996, states that the Apatient entered the office complaining of low back pain.@ There is no entry in the March 11 chart note concerning an incident on March 10, 1996. However, on a AHistory Profile@ completed by the employee on March 12, 1996, the employee reported that his pain began on Sunday [March10].
Dr. Luoma provided the employee with a chiropractic adjustment on March 11. The employee received 11 chiropractic treatments from March 11, 1996 through April 3, 1996, and on each date, the employee reported pain in his lower lumbar spine. On March 20, 1996, Dr. Luoma=s chart notes states as follows: ALittle sore after working today but generally states that he is doing much better.@ In late March 1996, the employee reported continuing mild pain in his lower lumbar spine. On each of his four chiropractic visits between March 25 and April 1, 1996, the same entry is typed in Dr. Luoma=s chart notes:
The patient felt better after the last treatment. Patient continues to experience mild pain in the lower lumbar spine. The examination revealed tenderness to palpation L4-5. Also noted is moderate spasm of the paralumbar muscles. The patient is progressing satisfactorily. Treatment today consisted of an adjustment.
(Er. Ex. 1.)
The employee testified that he missed one or two days of work during the week of March 11, and part of the following week. (T. 66.) He also worked in a different capacity for approximately one week following the March 10 incident due to symptoms in his low back. According to the employee=s testimony, by the time the employee returned to his regular machining duties, two weeks after this incident, he was Astill having problems with it [his low back].@ (T. 41.) On April 3, 1996, the employee reported to Dr. Luoma that his low back pain Astarted yesterday at work and [I] didn=t go to work yesterday as a result.@ Dr. Luoma wrote a memo on April 3, 1996, in which he stated, in part: AMr. Karakash was seen in our office today for treatment of a lower back condition. I feel it would be in my patient=s best interest to stay off of work Thursday April 4, 1996 through Friday April 5, 1996 to allow his condition time to heal.@
The employee remained off work those two days. He returned to work on Monday, April 8, and reported back to Dr. Luoma later that day for additional chiropractic treatment. According to Dr. Luoma=s chart note on that date, the employee experienced pain after working for two hours on April 8. The employee also reported headaches and neck pain to Dr. Luoma, for which Dr. Luoma was not treating at that time. At the hearing, the employee described the April 8, 1996, incident as follows:
A. I picked up a part one morning, I turned to put it on the machine and my back, on the left side, the muscles just spased [sic] out.
Q. When you say it spased out, what do you mean by that?
A. A sharp stabbing pain like.
A. On the left side of my lower back.
(T. 41.) On April 8, Dr. Luoma provided an adjustment of the employee=s low back, suggested that he not return to work that day, and recommended that he return the following day for additional chiropractic treatment. At his April 9, 1996 appointment, Dr. Luoma recommended that the employee remain on light-duty work until his low back strengthened. Dr. Luoma assigned physical work restrictions of no lifting over ten pounds and duties which provide the ability to change positions frequently. The employee attempted to return to work for the employer within those restrictions. He testified that he was refused the opportunity to work on a light-duty basis. As of the date of the hearing, February 23, 2000, the employee had not yet returned to work.
On April 12, 1996, the employee apparently advised Dr. Luoma that he was Amaking a comp claim@ relative to his low back condition. Dr. Luoma=s records included two AWorkman=s Compensation Form[s],@ undated. On one of those forms, when asked to list the date and time of the accident, the employee responded Aprogressive.@ In response to a question as to Awhere were you taken after the accident?@ the employee responded Ahome - 3-11-96 chiropractor (Luoma).@ The employee stated that he felt pain in his neck, head and back. The employee also attached a narrative report to that form, advising that during the last two years he experienced dizziness, neck pain, headaches, lower back pain and numb arms, and that these symptoms had progressively worsened, especially his severe headaches. (Er. Ex. 15.)
On the second undated form, the employee listed April 8, 1996, 10:00 a.m., as the date and time of his accident. On that form, the employee stated that he felt Asharp pain in lower back could not bend,@ and that he had reported his injury to Aaron Klima, one of his co-workers who testified at the hearing. On an attached narrative form, the employee stated as follows:
I went to work on Monday the 8th of April. I picked up about 209 forging[s] weighing about 75 lb. a piece. When I picked up the last part my back gave out as I was turning to put it on the machine. I felt sharp pain in my lower back and instant tightness. That=s when I reported my injury to Aaron. I went to Dr. Louma=s office for treatment.
(Er. Ex. 15.)
The employer and insurer filed a First Report of Injury on April 17, 1996, referring to an injury date of April 8, 1996. The employer and insurer also filed a notice of denial of liability on April 17, denying that the employee had sustained a work-related injury on April 8, 1996.
Dr. Luoma completed a AHealth Care Provider Report,@ which is a Department of Labor and Industry form, on April 18, 1996. He listed no date of injury on that report, but did report that the employee=s injury was work-related. According to Dr. Luoma=s report dated April 29, 1996, the employee provided the following history to him: AJohn stated that he sustained an on-the-job injury progressively and described the injury as occurring in the following manner: >throughout the past two years, I have experienced dizziness, neck pain, headaches, lower back pain. This has been getting progressively worse.=@ (Er. Ex. 15.) In that report, Dr. Luoma gave no opinion concerning the causation of the employee=s low back or neck condition, and did not specifically refer to the home incident on March 10, 1996, nor the April 8, 1996 work incident.
At the referral of Dr. Luoma, the employee consulted Dr. Jed Downs, in Duluth Clinic=s Department of Occupational Medicine, on April 25, 1996, regarding his dizziness and headaches. Dr. Downs referred the employee to physical therapy for treatment of his neck symptoms. Also at the referral of Dr. Luoma, the employee also consulted Dr. Skip Silvestrini, Department of Physical Medicine and Rehabilitation, on May 15, 1996 for his dizziness, neck and low back symptoms. Dr. Silvestrini diagnosed that the employee likely had a musculoskeletal strain in his low back, and determined that the employee was not on an adequate exercise program to strengthen his low back. He therefore referred him for physical therapy and a home exercise program. Dr. Silvestrini recommended that the employee be evaluated by an ENT specialist to exclude the possibility of middle or inner ear difficulties. In his report dated May 15, 1996, Dr. Silvestrini also stated that AI am totally at a loss as to the cause@ [of the employee=s dizziness]. Dr. Silvestrini also recommended a psychiatry evaluation to address the employee=s anxiety.
On May 16, 1996, the employee wrote to Dr. Luoma, stating that Dr. Silvestrini recommended physical therapy and also stating
I would appreciate it if you could send me a detailed report of your diagnosis of my injuries and your opinion of the cause of them. I feel that since I had gone back to work after being treated by you the first time, and my back went out again at work, it should be a worker=s compensation claim.
(Er. Ex. 15.)
Dr. Silvestrini again examined the employee on June 6, 1996; Dr. Silvestrini reported that he spent about 25 minutes with the employee, reviewing all of his symptoms. He also referred to the MRI of the cervical spine taken on March 18, 1996 at the Mayo Clinic. The primary focus of that examination apparently was on the employee=s neck and upper back symptoms, which Dr. Silvestrini concluded that he could not say, with any degree of certainty that those symptoms were related to the employee=s workplace exposure.
On May 20, 1996, the employee underwent an evaluation with an otolaryngologist who diagnosed a high frequency sensorineural hearing loss on the left, probably noise induced, and recommended ear plugs for work. He also noted symptoms secondary to tension and referred the employee for a psychiatric evaluation for this tension.
On June 12, 1996, Dr. Jed Downs wrote to the employee, apparently referring primarily to the employee=s multiple symptoms in his neck and upper back, stating as follows:
I have reviewed my clinic note as well as Dr. Silvestrini=s clinic note and Dr. Dobb=s clinic note. I have no question that you lift significant amounts of weight when at work, but you have not described to anyone a specific incident which caused your feeling to come at work, and your physical exam findings thus far have not demonstrated findings which any of the multiple physicians that you=ve seen can base your symptoms upon. . . . at this juncture I have no evidence upon which to base an opinion which would support your contention that this is work-related.
(Er. Ex. 15.)
The employee received chiropractic treatment for his low back and neck three times in May 1996 and three times in July 1996. In a report dated July 30, 1996, Dr. Luoma provided an opinion concerning causation, stating as follows:
Mr. Karakash=s job involves repetitive type of work, which is also, incorporated with frequent heavy lifting and twisting.
With job requiring activities involving repetitious twisting, lifting, leaning forward postures & positions over an extended period of time, microtears of the muscles and ligaments occur. In turn, this results in chronic weakening of the ligamentous and muscular supportive structures allowing the involved spinal areas more susceptible to injuries.
Based on our review of Mr. Karakash=s x-rays, history, evaluation, and job description, I am of the opinion Mr. Karakash=s current lumbar spine condition could very possibly be the result of such exacerbations due to chronic weakening of the ligamentous and muscular structures.
(Er. Ex. 15.) By August 27, 1996, Dr. Luoma released the employee to return to work within physical restrictions.
On February 17, 1997, the employee was examined by Dr. Thomas Litman at the request of the employer and insurer. The employee reported complaints of neck pain, headaches, intermittent numbness and tingling in his hands, persistent feeling of dizziness, and Amoderate residual low back pain without radiation into his legs, and without numbness, tingling, or weakness in the legs.@ The employee reported that from time to time, the low back pain was quite disabling. Dr. Litman concluded that he could not relate any of the employee=s complaints to his work activities, and that the employee had reached maximum medical improvement Afrom any condition from which he might be suffering@ and had no ratable disability of his body due to his spine. (Er. Ex. 15.)
Due to the employee=s lower back and left leg pain, Dr. Luoma later referred the employee for an MRI of the lumbar spine, which was taken on November 19, 1997, and which detected a herniation at the L4-5 level and three-level degenerative disc disease. Dr. Luoma then referred the employee to Dr. Alexander Lifson at the Low Back Institute. Dr. Lifson evaluated the employee on December 2, 1997, and recommended a five-day course of physical therapy, continued home exercises, and surgery if his radicular pain into his left leg continued. On January 30, 1998, Dr. Lifson performed surgery on the employee in the nature of a laminotomy at the L4-5 level. The employee testified that his leg pain subsided almost immediately after that surgery. (T. 56.)
On March 31, 1998, after reviewing updated medical records, Dr. Litman concluded that Asomething very drastic must have happened to Mr. Karakash=s lumbar spine@ between his exam in February 1997 and an MRI taken in November 1997 which detected three-level degenerative disc disease and disc herniation at one level. Dr. Litman recommended that a careful review be done of all of the employee=s chiropractic records and any records generated after February 1997 to determine the cause of the condition, such as an intervening factor, which necessitated the employee=s 1998 surgery. (Er. Ex. 7 and 12.)
The employee has not worked since April 8, 1996. He obtained rehabilitation assistance through the Minnesota Department of Labor and Industry/Vocational Rehabilitation Unit and conducted a job search post-surgery, including review of newspaper ads and internet postings. On November 12, 1996, the employee filed a claim petition, alleging that he sustained a Gillette-type work-related injury to his low back and neck on March 11, 1996. He claimed entitlement to temporary total disability benefits from April 8, 1996 to the present and continuing, a minimum of 9 percent permanent partial disability of the body as a whole, and payment for chiropractic expenses. The employer and insurer denied primary liability for the employee=s injury, alleging that the employee had injured his back at home while shoveling snow, and alleging that the employee had provided no medical documentation which causally relates the employee=s work activities to an alleged Gillette-type injury to his low back and neck.
A hearing was held before a compensation judge on February 23, 2000. On June 6, 2000, the judge served and filed a Findings and Order in which he determined that the employee has failed to prove that his low back condition was caused or substantially aggravated or accelerated by his work-related duties. Accordingly, the compensation judge denied the employee=s claim in its entirety. The employee appeals.
STANDARD OF REVIEW
In reviewing cases 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 (1992). Substantial evidence supports the findings if, in the context of the entire record, Athey are supported by evidence that a reasonable mind might accept as adequate.@ Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984). Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed. Id. at 60, 37 W.C.D. at 240. Similarly, A[f]actfindings are clearly erroneous only if the reviewing court on the entire evidence is left with a definite and firm conviction that a mistake has been committed.@ Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975). Findings of fact should 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.@ Id.
The issue to be determined on appeal is whether substantial evidence supports the compensation judge=s conclusion that the employee=s low back condition was neither caused nor substantially aggravated or accelerated by his work-related duties.
The compensation judge reviewed the various medical opinions and records to determine whether the employee developed a Gillette-type injury as a result of his employment with the employer, and specifically to determine whether the employee=s work activities caused or substantially aggravated or accelerated his low back condition, with a disability culminating on April 8, 1996. The compensation judge=s findings and order and his memorandum outline his review of medical reports in the record. The compensation judge cited specifically to the chiropractic records of Dr. Arne Luoma and to the medical records of Mayo Clinic, Center for Diagnostic Imaging, Dr. Jed Downs, Dr. Skip Silvestrini, and Dr. Alexander Lifson. The compensation judge based his conclusions on what he found to be a lack of medical support for a determination that the employee sustained a specific work-related injury on April 8, 1996, or a Gillette-type injury that culminated in disability on April 8, 1996.
"The employee has the burden of establishing that a work-related injury caused his or her disability." Tolzmann v. McCombs-Knutson Assocs., 447 N.W.2d 196, 198, 42 W.C.D. 421, 424 (Minn. 1989). "The burden is on the employee to prove by a fair preponderance of the evidence that she is entitled to workers' compensation benefits." Fisher v. Saga Corp., 463 N.W.2d 501, 501, 43 W.C.D. 559, 560 (Minn. 1990). "As a condition precedent to recovery under the Workers' Compensation Act, an employee has the burden of showing that an injury arose out of and in the course of employment." Swanson v. Fairway Foods, 439 N.W.2d 722, 723, 41 W.C.D. 1010, 1013 (Minn. 1989). See also, Steinhaus v. F.B. Clements, 47 W.C.D. 22, 30 (W.C.C.A. 1992).
The compensation judge reviewed the employee=s medical records which predated his claimed injury date of April 8, 1996 and compared those with the employee=s medical records generated after April 8, 1996. He concluded that the records of the employee=s treating chiropractor, Dr. Luoma, did not reflect a major change in symptoms or findings on examination on April 8, 1996. The compensation judge specifically referred to the employee=s testimony that he aggravated his low back while at home on March 10, 1996, and cited to the 11 sessions of chiropractic treatment received prior to April 8, 1996. The compensation judge also pointed out that on April 3, the employee reported to Dr. Luoma that he felt his low back pain was work-related, even though the employee later alleged an April 8 work injury.
The compensation judge concluded that Dr. Luoma apparently never was given an accurate history of when and how the employee=s symptoms started on March 10, referring to Dr. Luoma=s various reports written following his examination of the employee on March 11, 1996. Even though the intake sheet on March 11, 1996, reflects that the employee=s pain began the previous day from an accident, in later reports Dr. Luoma refers to the employee=s symptoms prior to March 11, 1996. For example, Dr. Luoma=s report of April 29, 1996, quotes the employee=s history as follows: AThroughout the past two years I have experienced dizziness, neck pain, headaches, lower back pain. This has been getting progressively worse, especially headaches.@ Dr. Luoma=s reports of July 30, 1996, and January 9, 1997, both state that the employee Apresented himself to my office on March 11, 1996. His subjective complaints were lower back pain, headache, neck pain, dizziness, right arm pain, numbness in the arm and upper back pain,@ and that the employee had experienced those symptoms for the past two years. (Er. Ex. 15.)
The compensation judge also referred to Dr. Luoma=s April 8, 1996, office notes which simply reflect that the employee experienced pain after working a couple of hours. The compensation judge determined that ADr. Luoma=s reports that were submitted into evidence do not contain any opinions that the employee was injured on April 8, 1996 or that he became disabled from working on April 8, 1996 due to repetitive trauma as a result of his work activities.@ (Finding No. 21.) In his memorandum, the compensation judge further concluded that although Dr. Luoma=s reports referred to tenderness at L4-S1, consistent with an injury at the L4-5 level where surgery was eventually conducted,
[p]aradoxically, none of Dr. Luoma=s reports even mention the employee raking snow off his roof the day prior to his examination of March 10, 1996. Instead, Dr. Luoma attempted to related [sic] the employee=s low back symptoms to the employee=s work activities over the previous two years. Under the circumstances, Dr. Luoma=s reports and opinions are viewed by the Compensation Judge with great suspicion as to their relation to what actually happened to cause the employee=s low back symptoms. This is not to say Dr. Luoma did not report what he was told. It is to say that the reports do not correlate with what happened in the employee=s life, on and off work and do not adequately explain how the claimed work activities were a substantial aggravation or acceleration of his preexisting low back condition.
(Memo, p. 7.)
The compensation judge referred to the inconsistent histories in the employee=s medical records as to the purported causative factors of the employee=s low back condition. In his memorandum, the compensation judge stated as follows:
The history of the employee=s alleged injury is a maze of inconsistencies. The physicians supporting the employee=s claim that he was injured at work or by his work activities were never given a complete history or an adequate foundation on which to base their opinions.
* * *
Proof of a work related injury generally reflects consistency between an employee=s testimony, the medical records and the medical opinions. Here, the employee=s history has been inconsistent, and the physicians= opinions lack critical foundation. Under the evidence presented, the Compensation Judge is of the opinion the employee has not sustained his burden of proof that it is more likely than not he sustained a work related injury to his low back on April 8, 1996, or that he sustained an injury over time from his work related duties that culminated in disability on April 8, 1996.
(Memo, p. 6, 8.)
Based on the inconsistencies in Dr. Luoma=s reports, the compensation judge rejected Dr. Luoma=s opinion due to lack of adequate factual foundation. The compensation judge also concluded that Dr. Lifson=s opinion was based on an inadequate foundation since Dr. Lifson=s opinions were based on history provided by the employee=s former attorney which was not submitted into evidence, and since Athere was [no] evidence of record that Dr. Lifson received an accurate history of the employee=s medical history as it pertains to his low back. Whereas Aa doctor's opinion regarding causation which is based on an inadequate factual foundation is of little evidentiary value," Winkles v. Independent Sch. Dist. No. 625, 46 W.C.D. 44, 58 (W.C.C.A. 1991) (citing Welton v. Fireside Foster Inn, 426 N.W.2d 883, 41 W.C.D. 109 (Minn. 1988)), in this case, rejection of the doctors= opinions based upon lack of adequate foundation reflected application of an incorrect legal standard. The compensation judge equated lack of foundation with the adequacy or accuracy of the information provided to Drs. Luoma and Lifson. Foundation is actually an admissibility standard which determines a witness=s ability to testify on certain matters. AThe competency of a witness to provide expert medical testimony depends upon both the degree of the witness=s scientific knowledge and the extent of the witness=s practical experience with the matter which is the subject of the offered testimony.@ Reinhardt v. Colton, 337 N.W. 23 88, 93 (Minn. 1983). An expert=s lack of information, such as that alleged in this case, goes to the weight of his opinion rather than to its foundation. Crosby v. University of Minnesota, slip. op. (W.C.C.A. Mar. 2, 1995).
Dr. Luoma had treated the employee since at least March 11, 1996, conducted periodic examinations of the employee, obtained histories directly from the employee, referred the employee to specialists and was provided reports from those consultations on an ongoing basis. Dr. Lifson also examined the employee, took a history from him, reviewed his radiographic films and other medical records. As a general rule, this level of knowledge establishes a doctor=s competence to render an expert opinion. See Grunst v. Immanuel-St. Joseph Hosp., 424 N.W.2d 66, 68, 40 W.C.D. 1130, 1132-33 (Min. 1988). Under these circumstances, there wasAfoundation@ for Dr. Luoma=s and Dr. Lifson=s opinions, and the judge erred in concluding otherwise. See, e.g., Goss v. Ford Motor Co., 55 W.C.D. 361 (W.C.C.A. 1996) (a doctor=s opinion does not lack foundation merely because he may not have had a complete description of all of the employee=s job duties); see also Olson v. Menasha Corp., slip op. (W.C.C.A. Sept. 25, 1998); Trego v. Associated Leasing, slip op. (W.C.C.A. Jan. 9, 1998); Stuhr v. Northwestern Travel Serv., Inc., slip op. (W.C.C.A. Sept. 3, 1997). Accordingly, we conclude that the compensation judge could review those records in order to render his finding on causation of the employee=s injury.
Notwithstanding our conclusion that the compensation judge erred in rejecting Dr. Luoma=s and Dr. Lifson=s opinions on foundation grounds, it is clear that the compensation judge scrutinized those records and rejected their causation opinions since he found them to less persuasive than other medical opinions in the record, a reason distinct from Alack of factual foundation.@ Thus, the issue to be determined is whether the compensation judge=s rejection of Drs. Luoma and Dr. Lipson=s opinions as not being persuasive or credible, in view of other medical records and testimony, was reasonable in view of substantial evidence of record. We conclude that it was. When faced with conflicting medical opinions, 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). Where evidence is conflicting or more than one inference may reasonably be drawn from the evidence, the findings of the compensation judge are to be upheld. Redgate v. Sroga's Standard Serv., 421 N.W.2d 729, 734, 40 W.C.D. 948, 957 (Minn. 1988). Neither Dr. Downs nor Dr. Silvestrini concluded that the employee=s symptoms were due to his work activities. Based on all of the medical records in evidence and based upon testimony taken at the hearing, the compensation judge could reject the opinions of Drs. Luoma and Lifson and instead adopt the opinions of Dr. Downs and Silvestrini. We find no error in those conclusions.
In his notice of appeal, the employee argues that Athe findings and order were based on physicians= reports which did not pertain to my low back injury.@ It is true that the compensation judge referred to many physicians= reports which referred to the employee=s history of dizziness, headaches and neck pain. However, the compensation judge also referred to the employee=s medical and chiropractic records which reflected his reports of low back pain, and therefore we do not find any error by the compensation judge in reviewing all of the medical records, including those pertaining to non-low back conditions.
In his brief submitted on appeal, the employee also argues that certain errors exist in the compensation judge=s citation to specific medical records. We have reviewed the employee=s brief and those medical records carefully, to address whether inaccuracies exist. We conclude that the compensation judge=s findings and order reflect an accurate review of the medical records and cite to those records on which he relies to render his conclusions. Questions of medical causation fall within the province of the compensation judge. Felton v. Anton Chevrolet, 513 N.W.2d 457, 50 W.C.D. 181 (Minn. 1994). The compensation judge=s findings are supported by substantial evidence of record, including the employee=s medical and chiropractic records, and we therefore affirm the compensation judge=s findings that the employee failed to prove that his low back condition was caused or substantially aggravated or accelerated by his work activities with the employer.
 Gillette v. Harold, Inc., 257 Minn. 313, 101 N.W.2d 200, 21 W.C.D. 105 (1960).
 The employee=s claim petition refers to an injury date of March 11, 1996, but the later pleadings and the Findings and Order refer to an injury date of April 8, 1996. At hearing, the parties also referred to April 8, 1996, as the alleged injury date. The claim petition listed low back and neck injuries; at hearing, employee=s counsel confirmed that the employee was limiting his claim to the low back.
 The employee testified that he Amay have@ had low back pain as a result of this snowmobile accident although he underwent no medical treatment for his low back after that accident. (T. 59, 61.)
 We note that the judge did not issue a specific finding of fact concerning Dr. Thomas Litman=s examination and report. However, a compensation judge is not required to relate or discuss every piece of evidence introduced at the hearing. Braun v. St. John=s Univ., slip. op. (W.C.C.A. July 20, 1992); see Rothwell v. State Dep=t of Natural Resources, slip. op. (W.C.C.A. Dec. 6, 1993) (the fact that the compensation judge did not recite all medical evidence favoring the appellant=s position in the findings and order does not establish that that evidence was overlooked).
 It appears that this characterization of the history provided to Dr. Lifson is not entirely accurate. On December 2, 1997, the employee completed a APatient History Questionnaire@ included in Dr. Lifson=s records, in which the employee listed that he picked up a part at work and felt severe low back pain, and that he also had low back problems before that date along with neck pain and exhaustion. In addition, Dr. Lifson=s chart notes on December 2, 1997, reflect the history given by the employee about two snow shoveling incidents in 1993 and March 1996 which caused back pain, and an exacerbation of pain at work from picking up a heavy part on April 8, 1996.