RENATA E. WOJCHIK, Employee, v. WINONA COUNTY, SELF-INSURED/ALEXSIS-RSKCO, Employer/Appellant, and WISCONSIN PHYSICIANS SERVS., INC., and MAYO FOUNDATION, Intervenors.
WORKERS= COMPENSATION COURT OF APPEALS
DECEMBER 23, 2002
CAUSATION - SUBSTANTIAL EVIDENCE; ARISING OUT OF & IN THE COURSE OF - SUBSTANTIAL EVIDENCE; EVIDENCE - EXPERT MEDICAL OPINION. Substantial evidence, including adequately founded medical opinion, supports the decision of the compensation judge that the employee sustained an injury to her left knee arising out of and in the course of her employment.
Determined by Stofferahn, J., Rykken, J., and Johnson, C.J.
Compensation Judge: Rolf G. Hagen
DAVID A. STOFFERAHN, Judge
The self-insured employer appeals from the compensation judge=s finding that the employee sustained a work-related left knee injury in the nature of an injury to the saphenous nerve, and from the consequent denial of its petition to discontinue. We affirm.
Renata Wojchik began working as a home health care aide for Winona County beginning in 1991, providing home wound and catheter care, medical transportation and homemaking services for the employer=s clients. On March 12, 2000 she was assisting a client, a partial amputee, at his home. As she knelt down on her left knee to perform foot care for this client, she experienced a burning sensation in the knee when it touched the floor. The pain was relieved when she stood back up, but returned when she tried to kneel again.
She reported the incident to her employer after work that day, but did not seek immediate medical attention since she thought the symptoms would go away. However, her symptoms persisted whenever she bent her leg and her employer advised her to seek medical attention. On April 10, 2000, she saw Dr. Scott Turner at the Winona Clinic. She provided no history of a specific trauma but noted that, as a home health aide, she was on her knees frequently. On examination, Dr. Turner noted that the left quad was slightly weaker than the right and there was slight subpatellar swelling and tenderness on either side of the patella. He suspected anserine bursitis with a patellofemoral syndrome of the left knee. The employee was given samples of Celebrex and told to return if her symptoms persisted.
On April 18, 2000 the employee returned to Dr. Turner because of continued left knee pain. An x-ray was taken which showed no acute bone or joint abnormalities. The employee then came under the care of Dr. E. A. Crowell, an orthopedic surgeon at the Winona Clinic. She was treated with medication, exercises and a knee immobilizer, and was given work restrictions of no twisting or squatting. The employer was able to accommodate her restrictions and she kept working. On May 16, 2000 Dr. Crowell noted some slight improvement but the employee still had continuing symptoms and an MRI scan was recommended.
The employee was not happy with her lack of improvement, and instead began treating with Dr. R. S. Bovard at the Gunderson Clinic. In her initial visit on June 9, 2000 she gave a history of the onset of pain with bending down to perform foot care. No previous injuries of any sort to her left knee were noted. After an examination, Dr. Bovard concluded that the history and clinical findings were most consistent with a diagnosis of pes anserine bursitis. A different medication was prescribed, physical therapy was recommended, and work restrictions were continued. A bone scan, done at the Gunderson Clinic on June 14, was read as normal. The employee also underwent an MRI scan which, according to Dr. Bovard, showed Asome slight inflamation and/or fluid along the medial retinicular area consistent with previous strain.@ Dr. Bovard subsequently referred the employee to Dr. Susan Halter, a specialist in physical medicine and rehabilitation at the Gunderson Clinic.
At the time of the employee=s initial visit on August 2, 2000, Dr. Halter was concerned about the possibility of lumbar involvement, and recommended a lumbar spine MRI and an EMG of the lower extremities. The lumbar MRI showed some straightening of the normal lumbar lordosis but was otherwise normal. Dr. Halter changed the employee=s prescriptions and referred the employee to Dr. Gregory Fischer, also at the Gunderson Clinic, for a neurological evaluation. She also recommended a psychological evaluation.
The claims administrator for the employer denied the psychological evaluation, but authorized the employee to see Dr. Fischer, who saw her on September 7, 2000. Dr. Fischer took a detailed history from the employee and performed a neurologic examination, the results of which were essentially normal. His impression was of bilateral knee pain, worse on the left, but he did not believe this represented a neurological condition. He referred the employee back to Dr. Halter, who continued the employee=s medication and restrictions and recommended an orthopedic referral.
The orthopedic referral was denied by the employer=s claims administrator and instead the employee was scheduled for an independent medical examination (AIME@) with Dr. Mark Fischer on October 30, 2000. In his report of that date, Dr. Fischer concluded that the employee had left knee tendonitis consistent with pes anserine bursitis as a result of her injury of April 3, 2000 (sic). He further concluded that the type of injury as described was consistent with symptoms of the kind that the employee was experiencing. Dr. Fischer did not believe the employee was at maximum medical improvement. He recommended further treatment with an orthopedic specialist.
The employee saw Dr. A. T. Saterbak, an orthopedist at Gunderson Clinic, on November 16, 2000. Dr. Saterbak diagnosed knee pain of unclear etiology following occupational injury. On the basis of his clinical exam, he felt it was likely that the employee had either tendonitis of the medial hamstring or chronic pes anserine bursitis. A diagnostic injection was done in the left knee with minimal response. On follow-up on November 30, Dr. Saterbak advised the employee that he had no further treatment recommendations and explained to her that pes anserine bursitis was a prolonged inflammatory process somewhat like a tennis elbow or shoulder tendonitis.
The employee was also seen by Dr. Boland at the Gunderson Clinic for a psychological evaluation on January 15, 2001, at the recommendation of Dr. Halter. Dr. Boland concluded, AI see no evidence of significant psycho-social contribution to her pain disorder and psychological diagnosis is, therefore, deferred.@ The employee returned to Dr. Halter, who recommended an evaluation by another orthopedist for additional treatment options.
The employee saw the orthopedist, Dr. Richard Romeyn, at the Winona Clinic on February 8, 2001. Dr. Romeyn disagreed with the previous diagnosis of pes anserine bursitis and concluded instead that her symptoms were patellofemoral. He based his conclusion on the lack of results from treatment, the findings on physical examination and the mechanism of the injury, which he described as Aclassic@ for exacerbation of an underlying patellofemoral vulnerability. Because this diagnosis had not been made earlier, Dr. Romeyn did not anticipate that her symptoms would be reduced quickly. He recommended ongoing work restrictions and physical therapy.
When the employee returned to Dr. Romeyn on March 14, 2001, she described significant subjective progress. On March 29, the employee again returned to Dr. Romeyn and reported that a lidocaine injection recently done had not been of any help. Dr. Romeyn noted that he was not surprised and considered this further evidence that the previous diagnosis was incorrect. Dr. Romeyn also considered surgical intervention in the pes anserine area, citing the employee=s unhappiness with her continued symptoms, his opinion that the risk of morbidity was nil, and the belief that he had no other treatment to offer the employee. However, arthroscopic examination of the employee=s knee done on April 11, 2001 was normal, and the employee was then referred back to Dr. Halter.
Dr. Romeyn also suggested a saphenous nerve block since that nerve was located in the area of the employee=s discomfort. The nerve block was performed on May 2, 2001. The anaesthesiologist performing the procedure advised the employee that she could expect some relief but that she still might need a TENS unit for long term pain control.
The self-insured employer had initially accepted liability for the employee=s injury. On June 25, 2001, the employer filed a petition to discontinue, alleging that the employee=s work injury was a temporary injury and that any continued disability or need for treatment was a result of non work-related causes.
The employer sent the employee for another IME, this time with Dr. Bruce Van Dyne of Neurologic Consulting Services, on July 25, 2001. Dr. Van Dyne=s opinion was that the employee=s pain complaints did not arise from any organic process, that a diagnosis of pes anserine bursitis was excluded because of the lack of success in treatment, and that the onset of symptoms was Adifficult to explain.@ Dr. Van Dyne concluded that the employee did not need any additional medical care or work restrictions for her knee symptoms.
The employee testified at hearing that she had become frustrated with her lack of progress after treating with Dr. Romeyn and had decided to go to the Mayo Clinic as her Alast hope.@ Her initial evaluation there was on August 17, 2001. After a consultation with a neurologist, the employee=s care was assumed by Dr. Robert Yang, a physical medicine and rehabilitation specialist. His conclusion was that the employee had sustained a nerve injury involving the saphenous nerve in the course of her employment. The employee was prescribed Neurontin. The employee testified at hearing that this medication had been of benefit and that her pain level had fallen from six or seven on a ten point scale to two by the date of hearing. She also reported being able to be more physically active.
At the request of the employer, Dr. Van Dyne prepared an additional report on January 15, 2002, after reviewing the Mayo Clinic records. He disagreed with the conclusion that the employee had a saphenous nerve injury since she had not had any significant improvement following the nerve block at that site. He also concluded that the employee=s knee problem was the simply the result of ordinary knee flexion by the employee and that the same injury could have happened during flexion of the knee at home.
This matter came on for hearing before Compensation Judge Rolf Hagen on January 23, 2002. In his Findings and Order, served and filed April 16, 2002, the compensation judge found that the employee had sustained an injury to her left knee in the course of her employment in the nature of an injury to the saphenous nerve. The employer=s petition to discontinue was denied. The employer appeals.
The employer appeals from the compensation judge=s finding that the employee sustained a work-related injury to her left knee. The question of whether there was a causal relationship between the employee=s work activities on March 12, 2000 and her knee symptoms is a question of fact. 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). A trier of fact=s choice between experts whose testimony conflicts is to be upheld on appeal unless the opinion relied upon lacks adequate foundation. Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985).
The employer contends on appeal that substantial evidence does not support a finding that the employee sustained an injury which arose out of her employment. First, the employer argues that neither the employee=s testimony nor the medical records clearly reveal the specific nature and mechanism of the employee=s injury, and that the employee has accordingly failed to sustain her burden of proof that the injury was work-related. Second, the employer contends that, in the absence of such proof, and in accordance with the opinion of Dr. Van Dyne, it must then be assumed that the employee=s injury was merely idiopathic in nature and could have occurred regardless of her work activities upon normal flexion of the knee. As such, the employer suggests, the injury should have been found non compensable, citing Bohlin v. St. Louis County / Nopeming Nursing Home, 61 W.C.D. 69 (W.C.C.A. 2000), and other cases.
The compensation judge accepted the expert medical testimony of Dr. Yang, who opined that the employee had sustained a saphenous nerve injury, which he characterized as a relatively rare condition. Dr. Yang acknowledged that Athere is some uncertainty as to the exact mechanism of injury,@ but did not find this particularly unusual, noting that such a nerve injury Adoesn=t take a severe or disruptive force@ and could result an injury otherwise so minor or inconsequential that the exact mechanics of the occurrence of the injury might go unnoticed, with the patient only noticing the onset of pain during the injury-producing activity without recalling specific trauma. Dr. Yang found the employee=s history consistent with his test and examination findings, and, in light of the absence of any prior history of the symptoms, was of the view that the injury was caused by the employee=s work activities when she knelt to assist the employer=s home care client on March 12, 2000.
The absence of a specific explanation of the physical mechanism of the employee=s injury does not render the compensation judge=s reliance on Dr. Yang=s opinion improper. To establish medical causation, a medical opinion does not have to express absolute certainty, its truth need not be capable of demonstration, and it is sufficient if it is probably true. Pommeranz v. State, Dep=t of Public Welfare, 261 N.W.2d 90, 30 W.C.D. 174 (Minn. 1974).
The employer argues that Dr. Yang=s opinion lacked foundation and should not have been the basis for the compensation judge=s decision. Dr. Yang=s deposition was taken for cross-examination purposes and in the initial cross-examination Dr. Yang was unfamiliar with some of the employee=s history including the negative results of the saphenous nerve block. While that testimony may have raised questions as to foundation, on direct examination, after having been apprized of this additional information, Dr. Yang continued to opine that the employee had sustained a saphenous nerve injury related to her employment.
Similarly, Dr. Yang was unclear on whether the employee had been involved in patient transfer on the date of the injury. While he testified that knee trauma during such an activity would have a greater likelihood of causing a nerve injury, the compensation judge could reasonably conclude that the fact that the employee was not performing any patient transfer on that date would not have changed Dr. Yang=s opinions, in light of his testimony regarding the minimal trauma necessary to cause a saphenous nerve injury and his reliance on the onset of the employee=s pain in determining the activity causing the injury. The compensation judge, who characterized Dr. Yang=s opinion as credible, reasonable, and based upon adequate medical foundation, was aware of the purported foundational defects and apparently concluded, in the light of all the evidence in the case, that they were not material to the doctor=s opinion. We see no foundational defect of such an extent as would preclude Dr. Yang=s opinion from consideration.
Other medical evidence and expert medical opinion in the case also supports the compensation judge=s determination. The employer=s first medical expert, Dr. Mark Fisher, who diagnosed a pes anserine bursitis, found the injury as described by the employee to be consistent with the type of injury that could cause the kind of symptoms which the employee had. Similarly, Dr. Romeyn, who concluded that the injury was an aggravation of an underlying patella femoral vulnerability, stated that the mechanism of the injury was Aclassic@ for this diagnosis. In order for the employee to prevail on the issue of causation, it was not necessary for the doctors to agree on a specific diagnosis. Here, regardless of the diagnosis, several physicians agreed that an injury arising from the employee=s work activities was the cause of her symptoms.
The medical history and examination findings in the case also provide additional support for the compensation judge=s findings. Although the employee=s physicians have found her condition difficult to diagnose, and there is a paucity of objective findings, we note that the examining doctor at the time of her first medical appointment, less than a month after the injury, did find subpatellar swelling in the employee=s left knee. Further, the employee provided a consistent history to her health care providers as to how the injury occurred, the nature of her complaints, and the effect of the injury on her ability to function. Demonstration of causation by objective testing is not a necessary prerequisite to proof of causation.
We conclude that the employee=s testimony combined withe the opinions of Dr. Yang, Dr. Fischer and Dr. Romeyn provide substantial evidence supporting the compensation judge=s decision that she sustained a work related injury on or about March 12, 2000.
An employee=s injuries which follow as a natural incident of work arise out of the employment. Foley v. Honeywell, 488 N.W.2d 268, 272 (Minn. 1992). The compensation judge=s finding that the employee=s injury was causally related to her work activities is supported by substantial evidence.