RONALD S. LEHNER, Employee, v. COMO TRANSP., INC., and EMC INS. CO., Employer-Insurer/Appellants, and FEDERATED MUT. INS. CO., and ST. MARY'S DULUTH CLINIC HEALTH SYS., Intervenors.
WORKERS= COMPENSATION COURT OF APPEALS
NOVEMBER 1, 2004
CAUSATION - SUBSTANTIAL EVIDENCE. Substantial evidence, including expert opinion, supported the compensation judge=s decision that the employee=s 2001 fall at work was a substantial contributing cause of the employee=s bilateral cubital tunnel syndrome.
Determined by: Wilson, J., Johnson, C.J., and Pederson, J.
Compensation Judge: Paul D. Vallant
Attorneys: Louis A. Stockman, Petersen, Sage, Graves & Stockman, Duluth, MN, for the Respondent. Kathleen S. Bray, Hanft Fride, Duluth, MN, for the Appellants.
DEBRA A. WILSON, Judge
The employer and insurer appeal from the compensation judge=s decision that the employee has traumatic bilateral cubital tunnel syndrome as a result of an April 7, 2001, fall at work. We affirm.
The employee began working for Como Transport, Inc. [the employer], in April of 1998, delivering bulk oil by truck for use by ore boats. On Saturday, April 7, 2001, during a delivery, the employee slipped while descending the ladder of his truck and fell backwards, landing in a mud puddle and striking both elbows on the ground. The employee testified that the impact really jarred him and that he Afelt a sensation in both of [his] elbows like a tingling and it was like jolting, like [he] was getting electrocuted.@ The employee further testified that the sensation went away after a half an hour or so but returned that evening, leading him to take aspirin. He reported the fall to his supervisor when he saw him two days later, on Monday, April 9, 2001, but it is unclear whether the employee informed his supervisor about continuing symptoms. By that time, the employee testified, the symptoms were minor; AI knew that something was wrong but it was going away.@
Over the next several weeks, the employee allegedly began experiencing numbness in the ring and little finger on his left hand, pain in a muscle in that hand, and throbbing pain in his left elbow. He also began to notice a loss of left hand coordination. Subsequently, in June of 2001, the employee told his supervisor about his symptoms and eventually made an appointment with Dr.
The employee was initially seen by Dr. Wodrich on July 24, 2001. The doctor=s treatment note from that date indicates that the employee had been experiencing left arm numbness for two weeks, with A[n]o specific injury.@ Suspecting nerve involvement, Dr. Wodrich referred the employee for an EMG, which was performed on August 1, 2001, and revealed Amoderately severe left tardy ulnar neuropathy.@ In the history section of the EMG report, the examining physician noted that the employee had had the numbness Afor about a month@ and that the employee Afell on the left elbow about three months ago, but there was no known neurologic sequelae.@
The employee was subsequently seen by Dr. Jeffrey Klassen, on referral from Dr. Wodrich, for Aleft ulnar nerve neuropraxia.@ In the history section of his report, Dr. Klassen wrote as follows:
HISTORY OF PRESENT ILLNESS: The patient is a 53 y/o right hand dominant male who presents with a history of an injury to his left elbow sometime in April or May of 2000 [sic] at work. Apparently, he fell off a truck backward into a mud puddle. He had acute onset of pain in his left elbow with radiation into the ulnar distribution. His symptoms seemed to resolve over the next day or two, but following this and over the ensuing two to three months he had progressive onset of numbness and tingling into the fourth and fifth digits and pain into the forearm and hand. He has been evaluated. Electrodiagnostic studies were obtained showing a moderate to severe tardy ulnar nerve palsy, and he has been referred to me for a surgical consultation. Treatment to date has included only activity modification.
Noting that the employee already had marked atrophy in the hand, Dr. Klassen recommended surgery
and advised the employee to follow up with the employer regarding workers= compensation, because the injury occurred at work.
On November 13, 2001, the employee underwent left elbow subcutaneous anterior ulnar nerve transposition surgery, performed by Dr. Klassen. The employee testified that, in the period he was off work just prior to the procedure, his right arm started to bother him as well. He also testified that he had mentioned his right-sided symptoms to both Dr. Wodrich and Dr. Klassen but that the issue was not pursued because Ait wasn=t that bad.@ The employee returned to work, following his left arm surgery, in late January of 2002.
On May 12, 2003, the employee returned to see Dr. Klassen for recurrent numbness and tingling in the fourth and fifth digits on the left hand and Asimilar symptoms@ on the right. Dr. Klassen diagnosed recurrent cubital tunnel syndrome in the employee=s left elbow and cubital tunnel syndrome in the right elbow, and he referred the employee for an EMG. That test, performed June 11, 2003, showed improvement in the left tardy ulnar neuropathy, status post cubital tunnel surgery, and Anewly diagnosed@ right tardy ulnar neuropathy. The employee was offered but declined the option of surgery for his right-sided symptoms.
The matter came on for hearing before a compensation judge on January 29, 2004, for resolution of the employee=s claim for various benefits related to his April 7, 2001, fall at work. Issues included the nature and extent of the April 7, 2001, injury. Evidence included the employee=s medical records, including records relating to treatment for neck, shoulder, arm, and hand symptoms following a 1992 fall at a different employer, and the reports of independent medical examiners Dr. William Fleeson and Dr. Tilok Ghose.
In findings relevant to the current appeal, the compensation judge concluded that the employee had sustained work-related injuries on April 7, 2001, in the nature of traumatic bilateral cubital tunnel syndrome. 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 sole issue on appeal is whether substantial evidence supports the compensation judge=s decision that the employee=s bilateral cubital tunnel syndrome is causally related to his fall at work on April 7, 2001. Narrative reports from two physicians were submitted in connection with the question of causation. Both Dr. Ghose and Dr. Fleeson initially attributed the employee=s cubital tunnel syndrome to the employee=s April 2001 work injury. However, after reviewing additional records concerning a 1992 work injury with a different employer, including medical records containing references to hand and arm symptoms through 1995, Dr. Ghose changed his opinion, concluding that the April 7, 2001, incident was merely a temporary aggravation of a preexisting condition. Dr. Fleeson, in contrast, maintained that the employee=s previous treatment was not related to cubital tunnel syndrome but more likely related to a possible neck, shoulder, and wrist injury.
The compensation judge found in the employee=s favor on the issue, expressly accepting the employee=s testimony that his previous hand and arm symptoms were different and that he had not experienced any such symptoms for at least five or six years prior to his April 2001 fall. The compensation judge also expressly accepted the causation opinion of Dr. Fleeson over the causation opinion of Dr. Ghose.
On appeal, the employer and insurer argue that the record as a whole Acan only reasonably support the position@ that the employee=s April 7, 2001, work injury was a temporary aggravation of a preexisting bilateral ulnar nerve condition. In support of this argument, the employer and insurer point to references in the employee=s medical records, from 1992 through 1995, reflecting hand and arm complaints seemingly similar to those the employee experienced after his April 2001 fall. The employee testified, however, that those earlier symptoms did not seem to involve his elbows and that they had in any event resolved by 1995 or 1996, and there is in fact no evidence that the employee received treatment or was subject to any limitations for at least five years prior to his 2001 work injury. We would also note, in this regard, that, while the employee was seen by several medical providers from 1992 to 1995, none of those providers ever suggested that the employee was suffering from cubital tunnel syndrome. Rather, physicians at the time were focused on alleged injuries to the employee=s neck, shoulder, back, and right wrist.
More importantly, the compensation judge was clearly entitled to accept the causation opinion of Dr. Fleeson, who wrote, in part, as follows:
Mr. Lehner=s fall of several feet, to asphalt, backwards, striking his elbows, was the type of injury mechanism that can traumatize the ulnar nerves in the cubital tunnels at the elbows (the location is commonly known a the Afunny-bone@). In this location the nerves are relatively superficial and the area is easily traumatized. Mr. Lehner=s development of symptoms, then their brief diminution, then their progression until manifested by muscle wasting in the hand and documented by electrodiagnostic studies, are all pathognomonic of ulnar nerve injury and a subsequent entrapment syndrome.
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I am also aware from the material you sent me that there is some controversy or question about Mr. Lehner=s upper extremity symptomatology in the 1992 and/or 1995 time period and I have already stated that there is no evidence in the medical records that there was any pre-existing condition that caused or contributed to abnormalities in the cubital tunnel of either upper extremity.
Having studied the records from that time period, I find that all one can now really conclude with any degree of certainty is that he did fall, and that he probably did injure some portion of his upper extremity and/or shoulder girdle and/or neck, and that probably there was also a wrist contusion or strain. It also seems clear from the medical records that Mr. Lehner did have some kind of tingling, numbness, dysaesthesia, coolness, or similar symptomatology in the upper extremity or extremities in that time period, and that sometimes it occurred in cold weather.
The Mariner Clinic notes are only partially definitive on the exact diagnosis, and the chiropractic notes are so all-inclusive that they are not helpful, but the fact that Mr. Lehner felt relief from the chiropractic treatment suggests a neck and shoulder girdle injury. My reading of the records is that Mr. Lehner probably had a neck strain/sprain and shoulder joint or shoulder girdle strain/sprain and a wrist sprain or contusion in that fall. Nevertheless, it is overly simplistic, in fact erroneously one-dimensional, to make an argument along the lines of: Ahe had numbness in 1992 or 1995 so it must be the same numbness that he had in 2001." Any physician competent in musculoskeletal medicine knows that there are many possible causes of Anumbness@ in an extremity, and that whatever is responsible for numbness usually either a) is transient and disappears soon, or b) progresses until the cause is obvious and can be diagnosed. Ulnar nerve entrapment, if it once occurs, does not simply fade away and disappear, and there is absolutely no evidence in the chart that Mr. Lehner was suffering from ulnar nerve entrapment (cubital tunnel syndrome) in the 1992 or 1995 time period--if he had been it would have worsened relatively quick and resulted in a diagnostic workup and treatment.
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The relatively recent nature of the [cubital tunnel] injury was demonstrated by the fact that his muscle wasting reversed after surgical relief of the entrapment--muscle wasting would not have reversed if the condition had been present for six or nine years.
Contrary to the employer and insurer=s agrument, it is obvious that Dr. Fleeson did not Aignore@ the employee=s preexisting symptoms, and we find no basis to conclude that Dr. Fleeson=s opinion somehow lacks foundation.
Because substantial evidence, including the employee=s testimony and expert medical opinion, clearly supports the judge=s findings as to causation, we affirm the judge=s decision in its entirety. See Nord v. City of Cook, 360 N.W.2d 337, 37 W.C.D. 364 (Minn. 1985).
 The employee testified that, because he was a new patient, he had to wait weeks to be seen by Dr. Wodrich.
 Dr. Wodrich=s note refers at one point to right hand symptoms, but the parties agree that that reference is a clerical error and that the employee was seeking treatment for left arm and hand symptoms.
 Dr. Ghose=s first report deals only with causation of the employee=s cubital tunnel syndrome on the left; as of the date of that report, the employee had not yet been diagnosed with cubital tunnel syndrome on the right.
 For example, records from 1992 indicate that the employee was complaining of bilateral hand, arm, and finger numbness as well as the limited ability to grip objects with his left hand.