BARBARA J. BROERS, Employee/Appellant, v. E.F. JOHNSON and SENTRY INS. GROUP, Employer-Insurer.
WORKERS= COMPENSATION COURT OF APPEALS
FEBRUARY 27, 2002
EVIDENCE - CREDIBILITY; NOTICE OF INJURY; CAUSATION - SUBSTANTIAL EVIDENCE. Where the judge identified the employee=s credibility as an issue, and where the employee had not alleged a separate, subsequent, work-related injury or aggravation prior to her testimony at hearing, the compensation judge=s conclusion that the employee did not sustain a separate work-related injury or aggravation one month after her admitted work injury was not clearly erroneous and unsupported by substantial evidence, and the issue of notice of such an injury was moot.
MEDICAL TREATMENT & EXPENSE - REASONABLE & NECESSARY. Where the employee=s original symptoms had been confined to her wrist and now ranged all the way up her arm and into her shoulder and neck and face and ear, where the injury at issue was originally diagnosed as a wrist tendonitis while the medical treatment at issue was recommended as a diagnostic and therapeutic measure to address a possible thoracic outlet syndrome, where medical records indicated that thoracic outlet syndrome had at least twice been ruled out previously, where the employee had now seen over twenty different physicians in connection with her broadly varying complaints, none of them able ultimately, even upon evidence of completed surgery, to conclusively diagnose her problems beyond her early diagnosis of tendonitis, and where, in the opinion of the independent medical examiner, the employee=s broadly ranging symptoms were not even indicative of thoracic outlet syndrome to begin with, the compensation judge=s denial of the diagnostic measures and medical treatment at issue was not clearly erroneous and unsupported by substantial evidence.
Determined by Pederson, J., Johnson, J. and Rykken, J.
Compensation Judge: Bernard Dinner.
WILLIAM R. PEDERSON, Judge
The employee appeals from the compensation judge's conclusion as to the nature of the employee=s work injury and from the judge=s denial of the employee=s request for certain medical treatment. We affirm.
Barbara Broers= medical history since July of 1996 is long and complex. On July 3, 1996, Ms. Broers [the employee] sustained a work-related injury symptomatic as soreness in her right wrist while employed as an electronic assembler with E. F. Johnson. The job at which Ms. Broers was working at the time, at which she had been employed for about twenty-three years, entailed the use of various small to medium-sized hand-held tools, in the production of ceramic circuit boards for two-way radio products. The employee did not seek medical attention for her injury until July 22, 1996, when she saw family practitioner Dr. Mark Gray. Noting no history of any numbness or tingling into the employee=s fingers, little tenderness or swelling over the base of the thumb, no discoloration, normal x-rays and sensation into the hand, and good grasp and movement of the thumb without pain, Dr. Gray diagnosed tendonitis and prescribed anti-inflammatories and a wrist splint. The employee was forty-nine years old on the date of her injury and was earning a weekly wage of evidently about $532.20. E. F. Johnson [the employer] admitted liability for the injury and commenced payment of benefits. The employee apparently took a few days off work, but on August 8, 1996, she returned to see Dr. Gray with renewed discomfort. Dr. Gray noted that the employee had reported improvement in her condition until recently but Athinks her right hand looks puffy and darker in color sometimes.@ He also indicated, however, that A[b]oth hands are pink and equal in temperature now@ and AI don=t notice any significant swelling.@ On a diagnosis of Apain in right wrist, probably tendonitis,@ Dr. Gray prescribed medication and recommended that the employee perform no repetitive wrist movement for at least two weeks.
The employee=s symptoms apparently did not improve, and on August 28, 1996, she saw orthopedist Dr. Gordon Welke. Dr. Welke diagnosed possible carpal tunnel syndrome and prescribed a different splint and medication, eventually ordering an EMG and referring the employee to orthopedist Dr. Michael Kearney, who saw the employee on October 3, 1996. In his report on October 7, 1996, Dr. Kearney noted in his history that A[w]hen [the employee] was working she also had a blue discoloration of the fingertips one day.@ Upon examination, he found that the fingers on the employee=s right hand Adeveloped a somewhat deeper pink discoloration than the fingers on the left@ when she stood with her arms at her sides. Dr. Kearney diagnosed overuse symptoms and carpal tunnel syndrome on the right, recommending conservative treatment rather than surgery.
On October 22, 1996, the employee saw hand surgeon Dr. Melissa Barton, who recommended thoracic outlet stress testing, a second opinion regarding the myofascial arm pain, and injection treatment for the hand problems. The thoracic outlet stress testing proved negative, and Dr. Barton treated the employee with carpal tunnel injections, Athe only option I would have further at this point,@ and referred the employee to orthopedist Dr. Peter Daly. Dr. Daly saw the employee on November 25, 1996, when he diagnosed right shoulder, elbow, wrist, and hand myofascial pain and recommended three weeks of physical therapy. He indicated that he did not detect any cervical abnormalities that would contribute to the employee=s pain, and he hoped that the physical therapy would Abuild up her endurance for her work activities.@ The physical therapist=s report on December 26, 1996, indicated that the employee=s therapy resulted in Alittle if any change in her symptoms,@ and Dr. Daly ordered a bone scan to better diagnose the employee=s complaints and assess the possibility of reflex sympathetic dystrophy [RSD]. The bone scan, conducted on January 7, 1997, proved normal, and Dr. Daly referred the employee to the Mayo Clinic to rule out either RSD or thoracic outlet syndrome. The employee was evaluated at the Mayo Clinic on various bases between February 18, 1997, and March 25, 1997. In a report to Dr. Daly on the latter date, Dr. Dietlind Roedler indicated that focuses of the employee=s evaluation had included, in addition to her right hand problems, the possibility of cardiovascular discase, vascular problems, and rheumatological disease. He indicated that two different Mayo physicians had recommended psychiatric evaluation for the employee, that physical therapy, exercises, Areassurance,@ and chronic pain therapy had also been recommended, and that Mayo physicians= final diagnoses were of chronic pain in the right upper extremity and mild left carpal tunnel syndrome. Upon receipt of this report, Dr. Daly referred the employee to the United Pain Center, noting on April 16, 1997, that he did Anot have anything further to offer her from an orthopedic standpoint.@
The employee was evaluated at the United Pain Center on April 16, 1997, by Dr. Todd Hess. Finding the employee to be Ain no acute distress,@ Dr. Hess diagnosed (1) chronic right hand and arm pain, probably due to mild carpal tunnel syndrome, (2) degenerative shoulder changes, possibly the cause of the employee=s shoulder and neck symptoms, and (3) lower cervical pain, probably myofascial. The employee received treatment at the United Pain Center for several months, including injection treatment and biofeedback therapy, but without much positive effect. On August 19, 1997, she underwent an MRI of her neck, which revealed broad-based disc protrusions at various levels. On September 11, 1997, on referral from Dr. Hess, the employee consulted with neurosurgeon Dr. Dan Tynan, who concluded that neck surgery would not be helpful.
On February 3, 1998, the employee began treatment with internal medicine specialist Dr. Christine Crader, who, on March 3, 1998, diagnosed right shoulder and arm pain and prescribed a muscle relaxant. When the employee returned after two weeks complaining of no relief from the medication and asking to see an orthopedic surgeon, Dr. Crader referred her to orthopedist Dr. William Laney. In his report on April 2, 1998, Dr. Laney diagnosed A[n]eck and right upper extremity complaints of pain with unknown etiology.@ Dr. Laney concluded that carpal tunnel release surgery was not indicated and that, if the employee should be found unimpaired by a neurologist, Athen I think that [the employee] could be working without fear of injuring herself.@ On April 23, 1998, the employee saw neurologist Dr. Irfan Altafullah, who ordered a repeat EMG. The EMG reflected a mild carpal tunnel syndrome, and Dr. Altafullah referred the employee for a surgical consultation with Dr. Steven Curtis. Dr. Curtis saw the employee on May 21, 1998, when he concluded that the employee had no clinical findings indicating that she would benefit from carpal tunnel release. On June 4, 1998, the employee returned to see Dr. Crader, who, at the employee=s request, ordered an ultrasound of the right upper extremity, to rule out a thoracic outlet syndrome and so Ato put th[at] issue to rest.@ The ultrasound apparently proved negative, and several weeks of physical therapy and a subsequent return to the pain clinic proved ineffective in eliminating the employee=s complaints. On August 21, 1998, having Alittle else to offer@ to the employee, Dr. Curtis concluded that carpal tunnel release surgery Acould logically help improve her hand numbness,@ although he did not expect it to improve her neck, pectoralis, or facial pain. Eventually, on October 23, 1998, Dr. Curtis performed that surgery on the employee=s right wrist.
About a month later, on November 24, 1998, the employee saw Dr. Altafullah again, who noted changing color in her hand, muscle spasm and tenderness in the right trapezius, and reduced grip strength. Dr. Altafullah concluded that there was Athe possibility of a vascular thoracic outlet syndrome@ and that, A[w]hile [the employee] does not meet the full-blown criteria for reflex sympathetic dystrophy, there are enough symptoms and signs to suggest that there may be some component of >sympathetically mediated pain=.@ On that conclusion, the doctor indicated that he Awould not hesitate to recommend one or two stellate ganglion blocks as a therapeutic trial to be followed by intensive hand therapy,@ and he referred the employee to thoracic surgeon Dr. John Overton.
Dr. Overton saw the employee on December 10, 1998. In his report on that date, Dr. Overton indicated that his Asuspicion in talking with [the employee] is that this is probably most related either to a degenerative cervical disease or spinal cord disease in the neck or some type of reflex sympathetic dystrophy.@ To assist in fuller diagnosis, he ordered repeat ultrasound scans of the employee=s subclavian veins and arteries, which revealed no evidence of any significant pathology. On January 21, 1999, Dr. Overton recommended further physical therapy, in addition to the three months that the employee had already had. He explained that he was not convinced that the employee was subject to a neurogenic thoracic outlet syndrome warranting surgery and that Amost patients who have benefit[t]ed from physical therapy have usually had a minimum of 3-6 months of therapy.@
On February 23, 1999, the employee returned to Dr. Altafullah, who, finding Anothing else to offer her,@ prescribed two diagnostic stellate ganglion blocks followed by more physical therapy. The employee eventually declined to have the injections, however, and, on April 19, 1999, she sought alternative treatment with physiatrist Dr. Karen Ryan. Dr. Ryan diagnosed thoracic outlet compromise, with possible right pronator syndrome, indicating that she Asuspect[ed] the neck, headache and upper back complaints are more related to the posture changes, from guarding her painful R arm than from other etiologies.@ She indicated also that the employee Adoes not appear, today, to have a RSD/complex regional pain syndrome, by history or exam, although her shiny skin does raise the question and she certainly is at risk for it.@ Dr. Ryan saw the employee again a month later, on May 17, 1999, when she noted that she suspected nerve entrapment at the pronator and recommended physical therapy and instruction in nerve gliding for the median nerve.
On August 31, 1999, Dr. Ryan diagnosed possible right pronator syndrome, indicating that an EMG, while it had not shown acute denervation in the median nerve distribution, had shown evidence of chronic neurogenic change. On September 29, 1999, the employee saw hand surgeon Dr. Paul Donahue, who confirmed forearm pronator syndrome and recommended surgical exploration and decompression. Dr. Donahue anticipated a good result on the employee=s forearm pain and paresthesias, but he was Aunsure . . . that it will have any effect on her upper arm and shoulder or neck symptoms.@ On October 5, 1999, apparently in light of that recommendation, the employer and insurer filed a Medical Request, seeking documentation of the employee=s treatment plan, asserting that they had Ano medical documentation since 05/17/99.@ On November 4, 1999, Dr. Donahue performed the proposed median nerve release surgery in treatment of the pronator syndrome. The employee apparently returned to work on November 17, 1999, and on November 23, 1999, the employer and insurer filed a notice of intention to discontinue the employee=s temporary total disability benefits on grounds of that return to work.
The employee followed up regularly with Dr. Donahue following her median nerve release, but that surgery ultimately had little effect on her symptoms. On February 23, 2000, despite therapy with stretching and nerve-glide exercises, she was Acontinuing to have symptoms, paresthesias in the right and small finger, pain in the upper forearm as well as neck and shoulder, radiating to the base of the skull.@ In light of these results, Dr. Donahue concluded that the employee=s ongoing symptoms might instead be secondary to thoracic outlet syndrome or possibly cervical disc disease. The employee returned to see Dr. Ryan, and, on June 30, 2000, after consultation with Dr. Overton and radiologist Dr. Thomas Gilbert, Dr. Ryan recommended that the employee undergo diagnostic injection of the pectoralis minor muscle with a local anesthetic and then, if that brought relief, follow-up injection therapy with Botox. On September 14, 2000, the employee filed a medical request for that treatment, based on her work injury on July 3, 1996. The employer and insurer had paid for all of the employee=s right upper extremity treatment since her July 1996 work injury, but in their medical response filed September 26, 2000, they denied this claim, on grounds that the employee Ahas had excessive treatment without any results,@ including Aboth passive and active modalities as well as injections and surgery.@
On that same date, September 26, 2000, the employee was examined for the employer and insurer by neurologist Dr. Bruce Van Dyne, who diagnosed right wrist tendonitis together with chronic pain syndrome without underlying organic cause, concluding that the employee might be subject to early Parkinson=s disease. Dr. Van Dyne concluded further as follows:
[I]t is my opinion that [the employee] does not have any specific symptoms or findings on examination that would be consistent with any residual injury or any other peripheral musculoskeletal or neurogenic process except that some of her symptoms of stiffness may be related to an underlying extrapyramidal syndrome that would be central in origin and entirely unrelated to her alleged work injury of 7/3/96.
It was also Dr. Van Dyne=s opinion that the employee did not currently require any specific restrictions related to her work injury, except perhaps that she should avoid highly repetitive tasks involving her right hand and fingers. Dr. Van Dyne concluded that the employee did not require any additional treatment or diagnostic studies related to her work injury, including either the proposed local anesthetic injection or the proposed potential Botox injections, in that she had no underlying condition that could reasonably be expected to respond to the latter. Dr. Van Dyne also concluded that, with regard to her work injury, the employee was not a surgical candidate, had reached maximum medical improvement, and was subject to no permanent partial disability.
On November 5, 2000, the employee was laid off from her job with the employer. On November 15, 2000, in light of Dr. Van Dyne=s diagnosis, Dr. Ryan referred the employee to Parkinson=s specialist Dr. Barbara Patrick. Dr. Patrick saw the employee on December 12, 2000, concluding at that time that there was Ano evidence, at this time, for Parkinson=s disease.@
The employee=s September 14, 2000, medical request for the injection treatment was addressed at an administrative conference on January 9, 2001. By a decision and order pursuant to Minn. Stat. ' 176.106, filed January 23, 2001, a mediator/arbitrator for the commissioner concluded that the injections at issue were not reasonably required in treatment of the employee=s July 3, 1996, work injury. On February 7, 2001, the employee filed a request for formal hearing.
On March 12, 2001, on referral from Dr. Ryan, the employee returned to the Minnesota Thoracic Associates, where she saw Dr. Gregg Anderson, in Dr. Overton=s absence. Dr. Anderson indicated that he Awould fully agree with and concur with the plan to use anesthetic injection therapy as our first line of treatment in this case,@ indicating also that, A[a]s a follow up position, if the anesthetic did prove to be at least partially successful, a pectoralis minor release from the coracoid could be attempted.@
The matter came on for formal hearing on April 24, 2001. Evidence submitted at hearing included payment logs indicating that the employee had, through October 26, 2000, already been paid $32,098.65 in medical benefits and $35,074.72 in disability benefits pursuant to her work injury of July 3, 1996. At hearing, the employee testified as to her work injury that A[a]ctually, I had two things happen because I had the tendonitis and I was working with the tendonitis and I made a wrong move to the right that turned my hand blue.@ The employee indicated that the latter event occurred about August 6, 1996, and that at that time she Acould feel [muscle tightness] all the way through my arm up into my front shoulder part.@ She testified that she sought attention that same day from the company nurse, who treated her by immersing her arm in warm water. On cross-examination, the employee conceded that she had no explanation as to why Dr. Barton=s notes indicated a history of the employee noticing discoloration in the hand Awhile she was still at work although she had finished her usual task. There was no known injury.@ The employee testified also that, on the day of the hearing, she remained subject to Aa burning in the tip of my ring finger,@Asymptoms that go through like my hand here,@ muscle tightness in the forearm, muscle spasm and tenderness up into the front pectoral muscles and into the neck, tightness in the neck, and tightness in her back that radiates up to her ear and into her face. She testified further that, on a scale of one to ten, her pain was most of the time at a level ten by the end of her work day.
Near the end of the hearing, the employee=s attorney alleged, for the first time, a separate work injury on August 6, 1996, having raised the issue neither in the employee=s medical request nor in his opening argument. He indicated that he had not referenced the injury earlier because he Acouldn=t have listed that. I didn=t know about that date until just today.@ He ultimately acknowledged that it appears as though Awhat happened on August 6th could conceivably be the explanation of the compression that she=s suffering from now so if we don=t have the second accident in there I don=t know if we=ve got anything that=s going to hold the thoracic outlet syndrome to the industrial accident.@ He conceded expressly that A[t]he only injury of July 3, 1996 is the tendonitis of the right arm,@ that A[t]here=s nothing about the right upper quarter@ in the injury on that date. Offering no objection to the motion that the issue of an injury on August 6, 1996, be added to issues for determination by the judge, the employer and insurer=s attorney asserted in response that Athe real issue is whether or not [the employee=s ongoing problems and need for treatment are] work related.@ A[W]e certainly have known that she=s claiming problems with her right upper extremity and I guess all along we=ve taken our own doctor=s word for it that the bluishness is part of the same thing so we haven=t had any notice problem with that.@
The hearing was continued, and in a post-hearing report to the employee=s attorney dated June 1, 2001, Dr. Ryan asserted an opinion that the employee Adefinitely had two separate work-related injuries involving her R upper extremity,@Aas she reported to me and to several other health care providers, as noted in her medical records.@ Dr. Ryan went on to support this opinion by stating,
Although I did not record a specific date for the second injury, when I saw her for the first time on May 17, 1999, her QRC, Michelle Theis, in her report of October 22, 1996 documents that [the employee=s] >right hand had turned blue and cold in the beginning of August.=
Dr. Ryan indicated also in her report that the employee=s continuing problems were best described as thoracic outlet compromise, the symptoms of which she dated to August 6, 1996, noting that Athe tendinitis symptoms which predated it limited [the employee=s] activity and use of the arm, thus predisposing her to the development of thoracic outlet compromise.@ On these conclusions, Dr. Ryan further concluded that the injection treatment here at issue was reasonable and necessary and causally related to the employee=s work for the employer.
Also in a post-hearing report, dated June 15, 2001, and addressed to the employer and insurer=s attorney, Dr. Van Dyne indicated that his review of Dr. Ryan=s June 1, 2001, report did not necessitate any change in the opinions he had expressed previously, in his report of September 26, 2000. He indicated that it remained his opinion that Athe sole injury sustained by [the employee] as a result of her work activities on or about July 3, 1996, was a tendonitis of the right wrist that has essentially resolved@ and that Aa tendonitis of the wrist would not predispose her to the numerous more proximal upper extremity pain symptoms that have subsequently evolved[Bin particular,] thoracic outlet compromise.@ He indicated further that, in his opinion, those symptoms were themselves not related to thoracic outlet compromise and that it remained his opinion that the employee did not require the injection treatment at issue, which, he asserted, is treatment not recommended under the workers= compensation parameters.
The record closed upon the parties= filing of memorandum briefs on June 26, 2001, and the compensation judge=s findings and order were filed August 3, 2001. As identified by the judge, issues for determination included the following: (1) whether or not, additional to a work injury of July 3, 1996, the employee sustained a work-related injury on August 6, 1996; (2) whether, if so, the employer received proper notice of that injury; (3) whether or not the recommended injection treatment at issue was reasonable and/or necessary for curing or relieving the effects of either the July 3, 1996, work injury or the alleged work injury on August 6, 1996; (4) whether those injections were reasonable and necessary in ruling out a claimed thoracic outlet syndrome; and (5) whether the employee was personally credible. In his findings and order, the judge expressly adopted Dr. Van Dyne=s opinion that the employee=s work injury on July 3, 1996, was in the nature of tendonitis of the right wrist, concluding also that the employee neither sustained nor gave notice of any work-related injury on August 6, 1996. In his accompanying memorandum, the judge indicated that the credibility of the employee=s testimony as to a sudden work-related appearance of upper arm, shoulder, neck, and discoloration symptoms on the latter date was controverted by Mayo Clinic records and by the fact that two days after the alleged August 6, 1996, injury there is no history of any injury on that date, no complaints of any upper arm problem, and no blue discoloration. On the basis of these findings and conclusions, the judge denied the employee=s request for the diagnostic and potential therapeutic injections at issue, based on either a July 3, 1996, or an August 6, 1996, work injury. 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 medical treatment here at issue was evidently intended to assist in either ruling out or diagnosing and treating thoracic outlet syndrome consequent to an injury on either July 3, 1996, or August 6, 1996. The compensation judge found that the employee=s admitted work injury of July 3, 1996, was in the nature of tendonitis of the right wrist and that the employee neither sustained nor gave notice of any subsequent work injury on August 6, 1996, as alleged. On those findings, the judge denied the treatment at issue. The employee contends that this decision by the judge was unreasonable in light of the bulk of the medical evidence and opinion of record. We are not persuaded.
1. The Alleged Injury on August 6, 1996
The employer and insurer commenced payment of benefits in this case based essentially on the basis of Dr. Gray=s July and August 1996 diagnosis of right wrist tendonitis, eventually paying for carpal tunnel surgery in that wrist and median nerve release surgery in the adjacent forearm. About a month after the admitted wrist/forearm work injury, the employee began complaining of additional symptoms of right hand discoloration and of pain ranging not only all the way up her right arm and into her shoulder and neck and face but also in the tendons of her left wrist. She testified at hearing that many of these symptoms first appeared at work on August 6, 1996, when she Amade a wrong move to the right@ at her work station. Clearly distinguishing this alleged August 6, 1996, event from the injury of July 3, 1996, the employee expressly testified that A[a]ctually, I had two things happen.@ In light of this testimony, which he indicated was information new to him on the date of hearing, the employee=s attorney alleged a second injury on August 6, 1996. The compensation judge, having identified the employee=s credibility as an issue, concluded at Finding 6 that the employee had not proven that she sustained any new and separate injury on August 6, 1996. We find that the judge=s conclusion in this regard was not unreasonable, not only in light of the apparent surprise of the allegation itself but also in keeping with our well established deference to a factfinder=s unique perspective in assessing the credibility of witnesses. See Brennan v. Joseph G. Brennan, M.D., 425 N.W.2d 837, 839-40, 41 W.C.D. 79, 82 (Minn. 1988) (assessment of a witness's credibility is the unique function of the trier of fact), citing Spillman v. Morey Fish Co., 270 N.W.2d 781, 31 W.C.D. 187 (Minn. 1978). Because it was not unreasonable, we affirm the judge=s finding that the employee has not proven that she sustained a separate work-related injury or aggravation on August 6. 1996. See Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239. Because we have affirmed the denial of an injury on that date, the issue of notice of such an injury is moot.
2. The Reasonableness, Necessity, and Work-Injury-relatedness of the Claimed Treatment
As would be true even had a new injury occurred on August 6, 1996, and as the employer and insurer=s attorney asserted at hearing, the real issue in this case is whether or not the employee=s ongoing problems and need for treatment are work related. We have already affirmed that the employee proved no new injury to have occurred on August 6, 1996, and no other new injury has been alleged. This renders the injury at issue to be that sustained by the employee on July 3, 1996, and confirmed as compensable in the judge=s unappealed Finding 3. The employee=s attorney expressly conceded at hearing that A[t]he only injury of July 3, 1996 is the tendonitis of the right arm,@ that A[t]here=s nothing about the right upper quarter@ in the injury on that date. In keeping with this concession by the employee, and based also on the diagnoses of Dr. Gray and especially Dr. Van Dyne, the judge also, in Finding 4, found the nature of the July 3, 1996, injury to have been tendonitis of the right wrist. The employee=s attorney had also conceded at hearing that Aif we don=t have the second accident in there [the alleged injury of August 6, 1996] I don=t know if we=ve got anything that=s going to hold the thoracic outlet syndrome to the industrial accident,@ and, the medical procedures at issue being essentially intended to assist in the diagnosis and potential treatment of thoracic outlet syndrome, the judge denied the employee=s claim.
The employee now contends on appeal that the work injury at issue was something other than the tendonitis diagnosed in July and August of 1996. In her brief, the employee argues that all of her evaluating and treating physicians except Dr. Van Dyne and the Mayo doctors concluded that she was subject to A[c]umulative trauma disorder (CTD) of the right upper extremity or the other names that it is known by, which include overuse symptoms and overuse syndrome.@ She identifies in support of this statement the diagnoses of Drs. Kearney, Barton, Daly, Roedler, Hess, Altafullah, Overton, Donahue, and Anderson. As suggested above, however, the treatment at issue, as recommended by Dr. Ryan in consultation with Dr. Overton and a radiologist, was recommended as a diagnostic and therapeutic measure to address a possible thoracic outlet syndrome. Nowhere in her argument has the employee successfully linked, by medical or other evidence, her admitted July 1996 wrist tendonitis condition with any existing or potential thoracic outlet syndrome. It may not be unreasonable to suggest that tendonitis might be a result of overuse and part of a cumulative trauma disorder, but the employee has offered no evidence that tendonitis, which her attorney has conceded to be A[t]he only injury of July 3, 1996,@ is related in any way to thoracic outlet syndrome.
The Mayo Clinic in the Spring of 1997 found no thoracic outlet syndrome, and Dr. Van Dyne in September of 2000 reached the same conclusion. Moreover, the complaints by the employee that have precipitated the recommended treatment at issue now range far afield from the locus of her original work injury. Whereas the original symptoms of the only work injury here at issue were focused only in the right wrist, the employee now complains of symptoms ranging all the way along her right upper extremity through her shoulder and up into her face and ear. The employee has now seen over twenty different physicians in connection with her broadly varying complaints, none of them able ultimately, even upon evidence of completed surgery, to conclusively diagnose her problems beyond her early diagnosis of tendonitis. Not only have neither these ranging symptoms nor thoracic outlet syndrome been definitively connected medically with the employee=s original wrist symptoms and diagnosis, but, in the opinion of Dr. Van Dyne, these symptoms are not even indicative of thoracic outlet syndrome to begin with. The compensation judge chose to rely on the opinion of Dr. Van Dyne, and, absent a showing that Dr. Van Dyne=s opinion was based on false factual premises, we cannot conclude that the judge=s doing so was unreasonable. See Nord v. City of Cook, 360 N.W.2d 337, 342-43, 37 W.C.D. 364, 372-73 (Minn. 1985) (A[t]he trier of fact's choice between experts whose testimony conflicts is usually upheld [unless] the facts assumed by the expert in rendering his opinion are not supported by the evidence").
Because the compensation judge=s finding as to the nature of the employee=s work injury was not unreasonable, and because it was also not unreasonable for the judge to implicitly conclude that the treatment at issue was insufficiently related to that injury, we affirm the judge=s denial of the treatment at issue. See Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.