JOLYNN GRENFELL, Employee, v. ZUMBROTA HEALTHCARE, and FARM BUREAU INS., Employer-Insurer/Appellants, and MN DEP'T OF ECONOMIC SEC., Intervenors.
WORKERS= COMPENSATION COURT OF APPEALS
NOVEMBER 24, 2004
CAUSATION - SUBSTANTIAL EVIDENCE. Substantial evidence, including expert opinion, supported the compensation judge=s conclusion that the employee=s work injury was a substantial contributing cause of the employee=s left knee condition and resulting disability.
Determined by: Wilson, J., Pederson, J., and Rykken, J.
Compensation Judge: Patricia J. Milun
Attorneys: Michael D. Miller, McCollum, Crowley, Moschet & Miller, Minneapolis, MN, for the Appellants. Van P. Jacobsen, Bird and Jacobsen, Rochester, MN, for the Respondent.
DEBRA A. WILSON, Judge
The employer and insurer appeal from the judge=s award of temporary total disability benefits. We affirm.
The employee has a history of left knee pain dating back to March 13, 2002, when she fell from a ladder at home. She was subsequently seen by physician=s assistant Kathleen Tangen, who diagnosed a left knee sprain. When seen by Dr. Santhi Subramaniam in follow-up on May 23, 2002, the employee continued to have pain in the medial aspect of the knee and complained that, when walking or turning, she would feel a sharp pain, and her knee would sometimes catch. Dr. Subramaniam diagnosed left knee pain "possibly secondary to a meniscal tear."
The employee saw orthopedic surgeon Dr. Steve A. Moen on June 10, 2002. At that time, the employee complained of a sense of catching and instability in the knee, and Dr. Moen ordered an MRI. The MRI, completed on June 11, 2002, revealed full-thickness articular cartilage fissure in the medial tibial plateau adjacent to the tip of the body of the medial meniscus. There was also Amild-to-moderate intrasubstance degeneration in the posterior horn of the medial meniscus@ but Ano evidence of a discrete meniscal tear.@
On June 14, 2002, after reviewing the MRI, Dr. Moen diagnosed a bone bruise or contusion, and he proceeded with a corticosteroid injection of the knee in response to the fissure in the medial tibial plateau. The employee was instructed to return to Dr. Moen if there were any problems with her recovery.
There is no evidence that the employee received any further treatment for left knee symptoms until March 11, 2003, when she slipped and fell, injuring her left knee, while working as a licensed practical nurse for Zumbrota Healthcare [the employer]. After this work injury, Dr. Robb G. Rutledge initially diagnosed a strain/sprain of the left knee, and, on April 1, 2003, he administered a cortisone injection. When seen in follow-up on April 29, 2003, the employee reported that, since the fall, she had Ahad sudden catching, almost giving out symptoms, where stepping and bearing weight will cause significant discomfort.@ At that point, Dr. Rutledge thought that there was a strong chance that the employee had a medial meniscus tear.
Another MRI of the employee=s left knee was performed on May 12, 2003. According to the MRI report, A[t]here is prominent signal abnormality within the substance of the body and posterior horn of the medial meniscus. This does not clearly extend to an articular surface and therefore does not meet the MR criteria for a meniscal tear.@ The MRI also revealed prominent degenerative arthrosis in the knee. On May 20, 2003, when the employee returned to Dr. Rutledge for a review of the MRI scan, Dr. Rutledge stated, Athe work comp injury in March this year aggravated a pre-existing condition, and because of that she is incurring the current symptoms and the need for medical expense.@ At that time, Dr. Rutledge was waiting for approval from the insurer to proceed with arthroscopy.
An arthroscopy and partial left medial meniscectomy was performed by Dr. Rutledge on June 30, 2003. The operative report indicated that the major findings were located in the medial compartment, Amainly a degenerative looking posterior horn of the medial meniscus along with advanced osteoarthritic change on both the tibial, as well as femoral surfaces of the medial compartment.@ July 10, 2003, office notes reflect that Dr. Rutledge had found degenerative changes within the medial compartment primarily, with a degenerative tear on the posterior horn of the medical meniscus and significant degenerative changes. At that time, Dr. Rutledge wrote that Areally this has to be considered an overall degenerative condition perhaps with just an aggravating occurrence at work . . . .@ The employee was advised to remain off work.
The employee was examined by independent medical examiner Dr. Richard N. Hadley on July 23, 2003. In the Ahistory of current injury@ portion of his report, Dr. Hadley stated that the MRI of May 12, 2003, had revealed Aa complex tear involving the posterior horn of the medial meniscus.@ In the discussion portion of his report, he stated that significant degenerative changes were noted on the MRI performed prior to March of 2003 and that A[i]t is anticipated that she will continue to have some degree of medial knee pain. It is also likely that Ms. Grenfell will experience some degree of acceleration of her underlying degenerative arthritis due to her partial arthroscopic medial meniscectomy.@ Ultimately, Dr. Hadley concluded that Abased on the currently available information the need for Ms. Grenfell=s arthroscopic surgery that was performed on June 30, 2003, is related to the injuries sustained on March 11, 2003.@ He went on to explain,
She had consistent symptoms following the injury on March 2003 that were not present prior to March 2003. She demonstrated significant intraarticular pathology on the MRI examination of May 2003 consistent with her pain and mechanical locking. The meniscus pathology is said not to have been present in the earlier MRI examination performed on 2002, but neither radiographic interpretation nor the actual study itself has been available for my personal review.
On July 31, 2003, Dr. Rutledge released the employee to return to partial or light-duty work as of August 13. On November 4, 2003, Dr. Rutledge again reviewed the arthroscopic images and found significant end-stage degenerative change on the femoral and tibial side of the medial compartment, which Aclearly pre-existed the fall she took in March.@ Dr. Rutledge went on to state, A[m]y feeling is that the Work Comp injury, i.e. the fall on the ice, produced an exacerbation of a pre-existing condition and that she is now well past the amount of normal healing time.@ He rated the employee as having a 3% whole body impairment as a result of the work injury.
Dr. Rutledge wrote to Michelle Duffney, a representative of the insurer, on November 17, 2003. In that letter, he stated, Athe restrictions we=ve placed on Jolynn have more to do with an underlying and pre-existing degenerative condition in her knee than with the injury from March of this year.@ AAt the present time, I would have to say that the restrictions that I have outlined are permanent, and I will leave it to you to determine whether that is due to her fall on the ice in March of this year or to her pre-existing condition.@
On December 15, 2003, the employer and insurer filed a notice of intention to discontinue workers= compensation benefits [NOID], alleging that the employee had reached maximum medical improvement [MMI] and that her restrictions were due to a personal pre-existing degenerative condition rather than her work injury. The employee filed an Objection to Discontinuance on February 11, 2004.
Dr. Hadley re-examined the employee on April 7, 2004. In his report of that date, he again stated that the MRI in 2003 had demonstrated a medial meniscus tear Aas well as some degenerative changes.@ It was further Dr. Hadley=s opinion that the employee had reached MMI by November 4, 2003, that the restrictions assigned by Dr. Rutledge were appropriate but could not be specifically attributed to the March 11, 2003, work injury, and that, since December of 2003, the employee had been incapable of her usual employment activities and was Aprobably totally disabled from most activities for which she has both training and experience.@
The employee=s objection to discontinuance proceeded to hearing on May 5, 2004. In findings filed on June 2, 2004, the judge found that the MRI of May 12, 2003, revealed a complex tear involving the posterior horn of the medial meniscus and that the employee=s work injury was a substantial contributing factor in the employee=s inability to work from November 4, 2003, to ninety days post-MMI. The employer and insurer appeal.
STANDARD OF REVIEW
On appeal, the Workers' Compensation Court of Appeals must determine whether "the 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 (2004). Substantial evidence supports the findings if, in the context of the entire record, "they 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, findings of fact should not be disturbed, even though the reviewing court might disagree with them, "unless 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).
The employer and insurer contend that the compensation judge=s award of temporary total disability benefits is unsupported by substantial evidence and clearly erroneous because Athe employee=s disability and need for restrictions from and after November 4, 2003, was due to her non-work-related, pre-existing degenerative joint disease.@ We are not persuaded.
The employer and insurer first contend that the judge erred in finding that the May 12, 2003, MRI revealed a complex tear. We disagree. The MRI report of May 12, 2003, does specify that the Asevere intrasubstance degeneration in the posterior horn of the body of the medial meniscus. . . does not clearly extend to an articular surface and therefore does not meet the MR criteria for a meniscal tear.@ (Emphasis added). However, in his report of July 23, 2003, Dr. Hadley stated that he had reviewed Aavailable records@ and noted that the MRI of May 12, 2003, Ademonstrated grade 3 and grade 4 erosions of articular cartilage on the medial compartment compatible with pre-existing degenerative arthritis. In addition, there was a complex tear involving the posterior horn of the medial meniscus.@ Dr. Hadley=s report provides substantial evidence to support the judge=s finding that the 2003 MRI demonstrated a complex tear of the medial meniscus. We therefore affirm that finding.
The employer and insurer also contend that the compensation judge=s findings as to the nature and extent of the employee=s work injury Aare not clear,@ that the judge mistakenly relied upon the opinions of Dr. Rutledge, and that the judge Amisapprehend[ed] Dr. Hadley=s opinions.@ We are not persuaded.
In Finding 8, the judge determined that Athe employee=s complex tear involving the posterior horn of the medial meniscus and subsequent arthroscopic medial meniscectomy led to an acceleration of the employee=s underlying condition identified by MRI on May 12, 2003.@ The judge went on, in Finding 9, to conclude that the employee had established that the work injury had accelerated a latent condition identified by MRI on May 12, 2003. The employer and insurer are correct in their assertion that the compensation judge did not specifically state that the meniscus tear was caused by the March 2003 injury. The compensation judge did, however, state that her findings were based on the opinions of Drs. Rutledge and Hadley, and those doctors= records and reports reasonably establish that the work injury either caused the complex tear of the medial meniscus or aggravated and accelerated the degenerative tear of the medial meniscus. In either event, the injury is compensable. In addition, both doctors opined that the work injury and the resulting surgery aggravated or accelerated the employee=s pre-existing degenerative condition, which on MRI is identified as arthrosis. Therefore, the compensation judge=s findings as to the nature and extent of the injury are not sufficiently vague to warrant reversal and are supported by substantial evidence in the record.
Evidence supporting the judge=s other findings includes the records and reports of Dr. Rutledge. In his May 20, 2003, office note, Dr. Rutledge indicated that the employee=s work injury in March of 2003 Aaggravated a pre-existing condition and because of that [the employee] is incurring the current symptoms and need for medical expense.@ On November 4, 2003, Dr. Rutledge reiterated that it was his Afeeling . . . that the Work Comp injury, i.e. the fall on the ice, produced an exacerbation of a pre-existing condition.@ Finally, in a letter to the employee dated May 4, 2004, Dr. Rutledge stated,
I agree that the fall you took on 3/11/03 was the main factor in the need to perform your surgery, 6/30/03. I also agree that the result of this injury and the subsequent surgery was an acceleration of your pre-existing degenerative knee condition, and because of that acceleration, you are now unable to function at your previous level of work.
The employer and insurer contend that Dr. Rutledge=s medical opinions are Ainsufficient as a matter of law as they are equivocal and speculative.@ We acknowledge that some of Dr. Rutledge=s records and reports seem to conflict with the opinions expressed above. Specifically, his November 17, 2003, report states that recommended restrictions Ahave more to do with an underlying and pre-existing degenerative condition of her knees than with the March injury.@ However, that statement would not preclude a compensation judge from finding that the work injury was a substantial contributing factor in the employee=s need for restrictions. Disability resulting from a pre-existing condition or infirmity is compensable if the work injury has aggravated or accelerated that condition. Wallace v. Hanson Silo, 305 Minn. 395, 235 N.W.2d 363, 28 W.C.D. 79 (1975).
The compensation judge also based her decisions in this matter on the opinions of Dr. Hadley. The employer and insurer contend that the opinions contained in Dr. Hadley=s July 23, 2003, report are faulty because Ahe was not able to review either the MRI studies or radiographic interpretations from either 2002 or 2003." However, in his 2003 report, Dr. Hadley gave detailed findings regarding the 2003 MRI, which were not contained in that MRI report, suggesting that Dr. Hadley had in fact reviewed the 2003 MRI study itself. This inference is supported further by Dr. Hadley=s comments on page 5 of his report, where he stated, A[s]he demonstrated significant intraarticular pathology on the MRI examination of 2003 consistent with her pain and mechanical locking. The meniscus pathology is said not to have been present on the earlier MRI examination performed on 2002, but neither radiographic interpretation nor the actual study itself has been available for my personal review.@ Thus is appears that Dr. Hadley was lacking only the 2002 MRI and report at the time of his July 23, 2003, report.
In his July 23, 2003, report, Dr. Hadley opined that the June 30, 2003, arthroscopic surgery was related to the employee=s March 11, 2003, work injury and that it was Alikely that Ms. Grenfell will experience some degree of acceleration of her underlying degenerative arthritis@ due to that surgery. The subsequent statement, set forth in his April 7, 2004, report, indicating that the employee=s restrictions Acannot be specifically attributed to the injury of March 11, 2003," does not preclude a finding that the work injury was a substantial contributing factor in the employee=s inability to work from November 4, 2003, to February 1, 2004.
Both Dr. Rutledge and Dr. Hadley opined that the employee=s arthroscopic surgery was related to the 2003 work injury and that that surgery would lead to an acceleration of the employee=s degenerative knee condition, and Dr. Rutledge specifically opined that, because of that acceleration, the employee was no longer able to perform the level of work she performed previously. Given this evidence, the record reasonably supports the judge=s findings of temporary total disability, and we affirm those findings in their entirety.
 This inference is further substantiated by Dr. Hadley=s April 7, 2004, report, in which he again stated that the 2003 MRI Ademonstrated a medial meniscus tear as well as some degenerative changes@ and then went on to discuss the 2002 MRI in a section of his report discussing additional information that Ais now available, which was not available at the time of her original examination.@
 The employer and insurer do not appear to dispute that the employee is totally disabled, only that the work injury was a substantial contributing factor in that disability.